The importance of breastfeeding to infant and young child ... · The importance of breastfeeding to...

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4 The importance of breastfeeding to infant and young child health and HIV-free survival

S e c t i o n 4 : T h e i m p o r t a n c e o f b r e a s t f e e d i n g t o i n f a n t a n d y o u n g c h i l d h e a l t h a n d H I V - f r e e s u r v i v a l

Key messages 2

4.1 HiV and infant feeding definitions and guidelines 3

w Keyelementsofthe2016HIVandinfantfeedingguidelines 3

4.2 Breastfeeding and HiV-free survival 5

w Theimportanceofbreastfeedingtoinfantandyoungchildhealth

andsurvival 5

w HIV-freesurvival 6

w Reducingpostnataltransmissiontovirtually‘Nil’ 7

4.3 Continued breastfeeding and weaning 9

w Durationofbreastfeeding 9

4.4 Positioning and attachment at the breast 11

w KeyPointstoenableattachment 11

4.5 expressed breastmilk and storage 12

w Benefitsofexpressingbreastmilk 12

w Howtoexpressbreastmilkbyhand 12

w Guidanceforstorageofexpressedbreastmilk 13

w Alternativepracticesutilisingbreastmilk 13

w Benefitsofreceivingtheheat-treatedbreastmilkof

amotherlivingwithHIVtothebaby 15

4.6 types of alternative feeding methods 15

w Cup-feeding 15

w Droppers 16

w Syringe-feeding 16

w Spoon-feeding 16

4.7 mixed feeding and replacement feeding 16

w Mixedfeedingbefore6monthsofage 16

w Healthoutcomesduetoformula-feeding,especiallyincreases

inoverallratesofinfantmalnutrition,morbidityandmortality 17

The importance of breastfeeding to infant and young child health and HIV-free survival

SECTION 4

taBle of Contents

2nd edition,2018

2 U n d e r s t a n d i n g I n t e r n a t i o n a l Po l i c y o n H I V a n d B r e a s t f e e d i n g : a c o m p r e h e n s i v e r e s o u r c e

w Nationalorsub-nationalhealthauthoritiesshoulddecidehowhealthserviceswillprincipallycounselandsupportmotherslivingwithHIVtoensurethegreatestchanceofHIV-freesurvival.Thedecisionhastobemadewhethertocounselandsupportfor:

• BreastfeedingandlifelongART,or • Avoidallbreastfeeding.w ARTreducestheriskofHIVtransmissionthrough

exclusive breastfeeding in the first six monthsandduringmixedfeedingaftersixmonths,andhasshiftedtherisk/benefitanalysis in favourofbreastfeeding.Whereverpossible,anHIVinfectedmother and her child should be given lifelongARV treatment or prophylaxis, while practisingexclusiveandcontinuedbreastfeeding,butifARVdrugsarenotyetavailable,exclusivebreastfeedinginthefirstsixmonthsandcontinuedbreastfeedingwithadequatecomplementaryfoodsremainthesafestoption;

w The aim of revised global infant feedingrecommendation is HIV-free survival of infantsandimprovedhealthandsurvivalofmotherslivingwithHIV;

w Mothers living with HIV should receive lifelongARVtherapy,arerecommendedtobreastfeeduntiltheirbabiesreachatleast12monthsofageandmaycontinuebreastfeedingforupto24monthsorlonger(similartothegeneralpopulation);

w ARV drugs given to the mother and babysubstantially reduce HIV transmission throughbreastfeeding, and exclusive and continuedbreastfeedingprovidesthemajorityofinfantswiththegreatestchanceofHIV-freesurvival;

w For mothers living with HIV in most settings,exclusive breastfeeding for six months, withappropriate antiretroviral therapy (ART ),and continued breastfeeding with adequatecomplementaryfoodstoatleast24monthsisthesafestfeedingoptionleadingtomaximumHIV-freesurvivalfortheirinfants;

w WhenmotherslivingwithHIVcontinuetoreceiveadequateARTfrom6to24months,theriskofHIVtransmissiontothebabyisverylow;

w Where antiretroviral (ARV) drugs are not yetavailable, exclusive breastfeeding in the firstsix months and continued breastfeeding withadequatecomplementaryfoodsremainsthesafestinfantfeedingmethod;

Key messages

w The very low risk of HIV transmission throughbreastfeeding with appropriate interventionsneeds to be balanced against the risk of illnessanddeathduetoreplacementfeedingespeciallyinresource-limitedsettings;

w Where ART is not yet available, exclusivebreastfeedinginthefirstsixmonthsandcontinuedbreastfeeding with adequate complementaryfoodsremainsthesafest infantfeedingmethod.However,everyeffortshouldbemadetoaccelerateaccesstoARVdrugs;

w Mothers living with HIV and healthcare workerscan be reassured that ART reduces the risk ofpostnatal HIV transmission in the context ofmixedfeeding.Althoughexclusivebreastfeedingisrecommended,practisingmixedfeedingisnotareasontostopbreastfeedinginthepresenceofARVdrugs;

w It was concluded that this makes exclusivebreastfeeding the best option for mothers whocannot sustain exclusive formula feeding, as isoftenthecaseinresource-poorsettings(Natchuetal.,2012);

w Mothers living with HIV should be advised tostop breastfeeding only when they can providea nutritionally adequate and safe diet withoutbreastmilkafter24months.Otherwisetheyshouldcontinuebreastfeedingupto24monthsorbeyondwhileremainingon(withfulladherenceto)ARVs.If breastfeeding is discontinued, this should bedone gradually over a period of 4 weeks whilematernal lifelong ARVs are continued (and withavoidanceofover-fullnessofthebreasts)inordertoavoidexposingtheinfanttoelevatedvirallevelsinbreastmilk;

w Theuseofthewoman’sownheat-treatedexpressedbreastmilkisasafealternativefortheHIV-exposedinfant;

w Mixed feeding in the first six months after birthcanincreasetheriskofpostnatalHIVtransmissioncomparedtoexclusivebreastfeeding,andthereforeshouldbeavoidedastheworstoption.Howeverthe2016recommendationformixedfeedingaftersix months reads:“Mothers living with HIV andhealth-care workers can be reassured that ARTreducestheriskofpostnatalHIVtransmissioninthecontextofmixedfeeding.Althoughexclusivebreastfeedingisrecommended,practicingmixed

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feedingisnotareasontostopbreastfeedinginthepresenceofARVdrugs.

w Some women living with HIV may seekinformationaboutalternativeinfantfeedingoptionsoutsidethenationalrecommendationand should be supported to make aninformedchoiceaboutthesafestwaytofeedtheirbabies.

w A simpler description of conditions for safereplacement feeding has been developedtoreplacetheAFASSdescription. Allcriteriashouldbeinplaceinallsettingswheremothersmightconsiderreplacementfeeding.Actiontoavoidspilloverofartificialfeedingtowomenwho do not need to use it is important forall infants including HIV-exposed infants.The International Code can protect womenand children from marketing of breastmilksubstitutes.

4.1 HiV and infant feeding definitions and guidelines

The following definitions of infant feeding are used(Labbok&Krasovec,1990):w Breastfeeding:feedingababyoryoungchildatthe

breast;otherfoodsmaybegiven.w Mixed feeding: feeding a baby with breastmilk as

wellasotherfoodsand/orliquidsbeforetheageof6months.

w Replacement feeding: intentionally replacingbreastmilkwithanotherkindofmilk,usuallyformulamilk.

w Exclusivebreastfeeding:thebreastfedinfantreceivesnootherfoodsandliquidsatall,apartfromprescribedmedications,notevenwater.

Key elements of the 2016 HiV and infant feeding guidelines

Researchshowsconclusively thatcarefuladherence tomaternal/infant antiretroviral (ARV) regimens duringpregnancy and breastfeeding greatly reduce verticaltransmission of HIV; and that exclusive and continuedbreastfeeding significantly improves overall HIV-freesurvivalratesofexposedinfants(Chikhunguetal.;Kuhn&Aldrovandi,2012;Chikhunguetal.,2016;Bispoetal.,

2017).EvenwhenARVsarenotavailable,WHOcurrentlyrecommendsthatbreastfeedingmaystill provide infants born to mothers livingwithHIVagreaterchanceofHIV-freesurvival.Nationalauthoritiesshouldnotbedeterredfromrecommendingthat mothers living with HIV breastfeed as the mostappropriateinfantfeedingpracticeintheirsetting(WHO&UNICEF,2016).MoststudiesfailtofindanyevidencethatbreastfeedingcausessignificantharmtothehealthoftheHIV-infectedmother.

TheWHOrecommendation(WHO&UNICEF,2016)isfornational and sub-national health authorities to decideon the strategy that will most likely prolong the livesandimprovethehealthofmotherslivingwithHIVwhilesimultaneouslyprovidingtheirinfantswiththemostlikelychanceofHIV-freesurvival.ThismeansthatmostmotherslivingwithHIVshouldreceivelifelongARVtherapyandthatarecommendationshouldbemadethattheyeitherbreastfeeduntil theirbabies reach24monthsormore(oruntilanadequatealternativedietcanbeprovided),or avoid all breastfeeding (WHO et al., 2010;WHO &UNICEF, 2016).While many assume this means that allHIV-exposedinfantsinindustrialisedcountriesshouldbeartificiallyfed,thisisbasedonthefalseassumptionthatnorisk is involved inartificial feeding; theKitprovidesevidence that women in such settings who want toexclusivelybreastfeedshouldbesupportedindoingso(Morrisonetal.,2011).

In its 2010 Framework for Priority Action (WHO et al.,2012),WHOproposesandclearlyoutlineshowtoachievefivepriorityactionsfornationalgovernmentsconsideredto be the gold standard in breastfeeding protection,promotionandsupport:w Developorrevise(asappropriate)acomprehensive

evidence-based national infant and young childfeeding policy which includes HIV and infantfeeding;

w Promoteandsupportappropriateinfantandyoungchild feeding practices, taking advantage of theopportunityofimplementingtherevisedguidelinesonHIVandinfantfeeding;

w Provide adequate support to mothers living withHIV to enable them to successfully carry out therecommended infant feeding practice, includingensuringaccesstoARVtreatmentorprophylaxis;

w Develop and implement a communication strategyto promote appropriate feeding practices aimedat decision-makers, health workers, civil society,communityworkers,womenandtheirfamilies;

� U n d e r s t a n d i n g I n t e r n a t i o n a l Po l i c y o n H I V a n d B r e a s t f e e d i n g : a c o m p r e h e n s i v e r e s o u r c e

w ImplementandenforcelocallytheInternationalCodeofMarketingofBreastmilkSubstitutesandsubsequentrelevantWorld Health Assembly resolutions (theCode).

Exclusive breastfeeding, a simple and cost-effectiveintervention to improve child health and survival, hasbeen estimated to avert 13% to 15% of under-fivemortalityandcontributetoreducepostnataltransmissionof HIV (Jones et al., 2003). While the prevalence ofexclusivebreastfeedingforinfantslessthansixmonthsislowinmostdevelopingcountries,greaterpoliticalwilltosupportbreastfeedingcouldincreasethoserates.For HIV-exposed babies, exclusive breastfeeding forthefirst6monthssignificantlyreducestheirchancesofcontractingHIVandlengthensthelifeofthosealreadyHIV-infected,andcontinuedpartialbreastfeedinguntilatleasttheendofthesecondyearhelpssafeguardtheirnutritionalstatus.

Current infant feeding recommendation for resource-poor settings Inresource-poorsettingswherediarrhoea,pneumoniaandmalnutritionarecommoncausesofchildmortality,breastfeeding with antiretroviral drugs is likely to giveHIV-exposed infants the greatest chance of HIV-freesurvival(WHO,2014a).

Current infant feeding recommendation for high to middle income countriesFor mothers living with HIV in high to middle incomecountriessuchasAustralia,Canada,SouthAfrica,UnitedKingdomandUnitedStates,nationalrecommendationandpoliciesmainlysupportreplacementfeeding.

HIV and infant feeding recommendation in Australia“In Australia breastfeeding is contra-indicated when amotherisknowntobelivingwithHIV(specialistadviceisneededforeachindividualcase)”(Morrison&Greiner,2014).

HIV and infant feeding recommendation in CanadaInCanadaitisrecommendedthatbreastfeedingshouldbeavoided,evenifthemotherlivingwithHIVisreceivingantiretroviral therapy.This is consistent withWHO’srecommendationincountrieswheresuitablebreastmilksubstitutesareavailable.CounsellingabouttherisksofHIVtransmissionduringpregnancyandlactationarean

important part of early prenatal care (Tudor-Williams,2010).

HIV and infant feeding recommendation in United KingdomThePositionPaperoftheBritishHIVAssociation(Tudor-Williams,2010)recognisesinparagraph3thatawomanliving with HIV already receiving triple ART, with arepeatedundetectableviral loadatdeliverymay,aftercareful consideration, choose to exclusively breastfeedforthefirst6monthsofherbaby’slife.Insuchascenario,thecurrentguidancerecommends:• continuingmaternaltripleARTtreatmentandshort-

terminfantprophylaxis.• exclusivebreastfeedingforsixmonths.• frequentfollow-up.• carefulmonitoringofmaternalARTadherenceuntil

1weekafterweaning.• monthlychecksonmaternalviralloadandinfantHIV

status.

HIV and infant feeding recommendation after amendment (June 2017) in South Africa • Exclusivebreastfeedingduringthefirstsixmonthsof

lifeisrecommendedtoallinfants,exposedornotHIVexposedorunknownHIVstatus;

• MotherslivingwithHIVonARTandwhoseinfantsareHIV uninfected or of unknown HIV status continuebreastfeeding for24months (recommended)whilebeingfullysupportedforARTadherence(asoutlinedinthecurrentPMTCTguidelinesofSouthAfrica). Inaddition,theinfantshouldreceiveprophylacticARVsinaccordancewithcurrentPMTCTguidelinesofSouthAfrica(Pillay,2017);

• Mothers living with HIV and whose infants are HIVinfected,shouldcontinuebreastfeedingfor2yearsorlongerwhilebeingfullysupportedforARTadherenceformotherandinfantpathology;

• The current SA IYCF policy/2017 strengthensthe position of no difference in breastfeedingrecommendationformothersregardlessoftheirHIVstatus.The recommendation have been designedto provide the same breastfeeding support to all,foroptimalinfanthealthandnutrition,andinorderto reduce discrimination, spill over and stigmaexperiencedbywomenlivingwithHIV.

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4.2 Breastfeeding and HiV-free surViVal

the importance of breastfeeding to infant and young child health and survival

Breastfeeding is advantageous in almost all settings,buttheHIV/AIDSepidemicanditspotentialforverticaltransmission,haschallengedtheestablishednotionofoptimalbreastfeedingforall(WHO,2001).

Recommendation and Guidance for the GeneralPopulationinAllCountries(WHO,2001;WHO&UNICEF,2003;SavetheChildren,2012)w startbreastfeedingwithinonehourofbirth.w breastfeedexclusivelyforthefirstsixmonthsoflife.w givenutritionallyadequateandsafe,age-appropriate

complementary foods after six months, whilecontinuingtobreastfeedforuptotwoyearsofageorbeyond.

exclusive breastfeeding for the first 6 monthsWith increasing recognition that in most developingcountries replacement feeding is neither affordable,feasible, acceptable nor, most importantly, safe orsustainable,alternativeresearchhasfocusedonwaystomakebreastfeedingsafersoastomaintainitsimportantgeneralhealthbenefits(Dohertyetal.,2007;Jamiesonetal.,2012;Natchuetal.,2012).

factors which increase the risk of HiV transmission during breastfeedingThereisanincreasedriskoftransmissionifthemotheris not receiving (or has recently begun) antiretroviraltreatment(ART)underanyofthefollowingconditions:• Ahighviralload,(e.g.>3500copies/mL)(Garciaetal.,

1999;Shapiroetal.,2009)dueto:– PrimaryinfectionwithHIVduringlatepregnancy

orduringthebreastfeedingperiod(Johnsonetal.,2012).

– Averylong-standingHIVinfection,withalowCD4count (<225 cells/mm3), which indicates activeAIDS(Shapiroetal.,2009).

– Short duration of ART, facilitating on-goingseedingofmilkbyvirusesfromtheblood(Slykeretal.,2012).

• Suffersbreastpathology,alsomorelikelywithahighviralload(>3500copies/mm3)orlowCD4count(<225cells/mm3):

– Inflamed/infected breasts (mastitis,abscess)(Sembaetal.,1999a;Willumsenetal.,2003;Semrau etal.,2011) (morelikelywithmixedfeeding)(Embreeetal.,2000).

– Bacterialorfungalnippleinfection(John-Stewartetal.,2004).

– Painful/damagednipples(Walkeretal.,2006).

InfantfactorswhichincreasetheriskofinfectionduringbreastfeedingintheabsenceofARTare:• oral thrush, though this may also be a proxy for

immune suppression (Hamza et al ., 2008), i.e. asymptomofanalready-infectedinfantwhoseimmunesystem has already been severely compromised byearlyHIV-infection(Chisengaetal.,2005).

• effects on the infant of frenulotomy for perceivedankyloglossia.

• mixedfeeding(i.e.breastfeedingplusotherfoodsorfluidsbeforetheageof6months)hascauseddamagetotheintestinalmucosa.

• early introduction of solid foods and animal milks(Coovadiaetal.,2007).

• partialbreastfeeding,becauseexclusivebreastfeedingprotects the integrity of the gastrointestinal tract,presentingamoreeffectivebarriertoHIV(Coovadiaetal.,2007).

Possible confounders regarding exclusive breastfeeding in the HiV contextSomeresearchershavealsonotedreversecausality,i.e.the association of exclusive breastfeeding with lowerratesofMTCTofHIVmaybesecondarytopoormaternalor infant health which in turn led to less exclusivebreastfeeding(Phirietal.,2006).

interventions to reduce the risk of HiV transmission through breastfeeding Sincethediscoveryin1985(Ziegleretal.,1985)thatHIVcanbetransmittedduringbreastfeeding,andrecognisingthattheriskofHIVtransmissioncontinuesthroughoutthebreastfeedingperiod(BreastfeedingandHIVInternationalTransmissionStudyGroup,2004;WHOetal.,2010),variousinterventionstoreducepostnataltransmissionhavebeenemployedindifferentcountries,including:• provisionoflifelongART(WHO&UNICEF,2016).• provisionofARVs tomothersand/orbabiesduring

thebreastfeedingperiod.• Modificationofinfantfeedingwith:

– completeavoidanceofbreastfeedingfrombirth,i.e.replacementofbreastmilkwithformulamilk.


– earlycessationofbreastfeedingat3-6monthstoreducethelengthoftimeforinfant’sexposuretovirusinbreastmilk.

– gradual cessation (weaning) to avoid increasingtransmissionduringthisperiod.

– exclusivebreastfeeding.– heat-treatingofmother’sownexpressedbreastmilk

toinactivateHIV.– useofheat-treatedbreastmilkfromamilkbank.

HiV-free survival

Revised recommendation capitalise on the maximumbenefitofbreastfeedingtoimprovetheinfant‘schanceofsurvivalwhile reducingthe riskofHIV transmission.In the presence of ARV interventions, being able tobreastfeedforupto24monthsor longeravoidsmanyofthedifficultiescausedbyendingbreastfeeding,i.e.inprovidingasafeandadequatediettoaninfantwithoutbreastmilk, and facilitating gradual weaning from thebreast.

recommendation on arVs and HiV transmission through breastfeedingSeveral important trialswithdifferingARVapproacheshavedemonstratedthatmotherswithHIVcanbreastfeedsafelyforlongerdurationsandthatthiscanbelifesavingfortheirinfants.Althoughlonger-termexposuretoARVsmayhaveundiscoveredconsequences,thebestavailableevidence suggests that the risk of infants dying fromotherdiseases ifbreastfeedingstopsbeforetheageof2isgreaterthanthepotentialsideeffectsofprolongeddrug exposure.Thus ARVs that reduce the risk of HIVtransmission through breastfeeding have shifted therisk/benefit analysis in favour of breastfeeding (Sint etal.,2013;Chikhunguetal.,2016).

Exclusivebreastfeedingshouldbestronglyencouraged(UNICEF, 2011;WHO & UNICEF, 2016). According to a2013 study, breastfed infants had a 47% lower risk ofpneumonia than those never breastfed, independentofinfantgrowth,maternalviralloadandmaternalCD4count.Breastfeedingwasalsoassociatedwitha74%lowerriskofpneumonia-relatedhospitalisation(Ásbjörnsdóttiretal.,2013).

Support of exclusive breastfeeding is a standard partof usual lactation management (WHO & UNICEF, 1993;Lawrence&Lawrence,1999).OutsidethecontextofHIV,increased rates of diarrhoea and respiratory infectionhavebeenassociatedwiththeearlyintroductionofnon-

humanmilksandsolidfoods(mixedfeeding)comparedtoexclusivebreastfeeding(Victoraetal.,1987;Brownetal.,1989;Ahmedetal.,1992;WHOCollaborativeStudyTeamontheRoleofBreastfeedingonthePreventionofInfantMortality,2000;Arifeenetal.,2001;Bahletal.,2005).

Exclusivebreastfeedingfacilitatesnormalphysiologicalregulationofmilkproductionandhelpstopreventmilkstasis which underlies the development of avoidablebreastproblems(Neville&Neifert,1983;Smith&Kuhn,2000; Semrau et al., 2011).This is especially necessarywhenawomanisinfectedwithHIV.

arV during breastfeedingWHOrecommendsthatwomenlivingwithHIVshouldbeprovidedwithlifelongARVtreatmentandinfantprophylaxisforseveralweeksafterbirth.EveryeffortshouldbemadetoaccelerateaccesstoARVsforbothmaternalhealthandpreventionofverticaltransmission(WHO,2010a;WHOetal.,2010;WHO,2012c;WHO,2016c).

The 2013 (WHO, 2013a) and 2016 (WHO, 2016c)WHOguidelinesrepresentanimportantsteptowardsachievinguniversalaccesstoARVdrugsfortreatingandpreventingHIV, and realising the ultimate goal of ending the HIVepidemic. The Consolidated Guidelines are valuableresourcesforcliniciansandshouldinformtheprioritiesof governments, development agencies, internationalorganisations,nongovernmentalorganisationsandotherimplementingpartnersduringthenextfewyears.

Pending universal access to ARVs, national authoritiesshouldnotbedeterredfromrecommendingthatwomenlivingwithHIVshouldbreastfeed.

Breastfeeding as the safest feeding optionExclusivebreastfeedingforsixmonths,withappropriateARVs, and continued breastfeeding with adequatecomplementary foods to 24 months or beyond is thesafest feeding option, leading to maximum HIV-freesurvivalinmostlow-incomesettings(WHOetal.,2010;WHO&UNICEF,2016).

Theknownbenefitsofbreastfeedingtoreducemortalityfromother infections justifyanapproachthatstronglyrecommendstheoptionofbreastfeedingplusARVsasthestandardofcare(WHOetal.,2010).ThisevidencehasmajorimplicationsforhowwomenlivingwithHIVmightfeedtheirinfants,andhowhealthworkersshouldcounselthem.SeeFigure1fordetails.

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Rather than presenting breastfeedingas an option, there are few currentresource-poorsettingsinwhichartificialfeeding is justified. Breastfeeding iscurrentlyalmostalwaysrecommendedformotherslivingwithHIVinresource-poorsettings:• enablingbreastfeedingtocontinueto

12monthswithARVinterventions.• providingadditionaldevelopmental

and other health benefits ofbreastfeeding for infants who donot become HIV-infected (Ahmedetal.,2013).

• eliminatingreplacementfeedingasthe sole way to avoid postpartumtransmissionofHIV.

• avoiding increased rates of infant morbidity and mortality due to withholding

breastfeeding.• avoidingthecomplexitiesassociatedwithstopping

breastfeedingandattemptingtoprovideasafeandadequatedietwithoutbreastmilktotheinfant6–12monthsofage(Wallsetal.,2010;ABA,2011;Morrisonetal.,2011).

• facilitatingthegreatestlikelihoodofinfantandyoungchildHIV-freesurvival.

• study on household food insecurity, maternalnutritionalstatusandinfantfeedingpracticesamongHIV infected women receiving ART in Uganda.HouseholdfoodinsecurityinthecontextofHIVhasbeen found to significantly influence cessation ofexclusivebreastfeeding,especiallybetween4and6months,andthecausalrelationshipbetweenmixedfeedingandaccesstosufficientfoodshouldbefurtherexplored(Youngetal.,2014).

good Practice and recommendation when arVs are not availableEven when ARVs are not available, breastfeeding maystill provide infants born to HIV-infected mothers witha greater chance of HIV-free survival. Mothers shouldbe counselled to exclusively breastfeed in the first sixmonths of life and continue breastfeeding thereafterunlessenvironmentalandsocialcircumstancesaresafefor,andsupportiveofreplacementfeeding.

good practice on parents living with HiV and HiV testing of childrenInallsettings,childrenwithparentslivingwithHIVshouldberoutinelyofferedHIVtestingand,iffoundtobeeitherinfectedorathighriskofinfectionthroughbreastfeeding,

FIGURe 1: balancing competing risks 4

Source:USAIDetal.(2010)

For HIV positive women: Does exclusive breastfeeding or replacement feeding with formula better protect my baby’s life?

If my baby and I take ARVs, what is the risk of passing HIV to the baby through

breastfeeding?

If I feed my baby infant formula, what is the risk of my baby dying of other causes

beside HIV?

shouldbelinkedtoservicesfortreatmentorprevention(WHO,2016a).

reducing postnatal transmission to virtually ‘nil’

recommendation and guidancePostnataltransmissionofHIV(i.e.throughbreastfeeding)canbereducedstillfurthertobetween0-1%when:• upon diagnosis, pregnant women living with HIV

haveaccesstoeffectiveARTwhichiscontinuedforlife(WHO,2013;WHO,2016a).

• ARTisprovidedforatleast13weekspriortodeliverytoachieveanundetectableviralloadbythetimeofbirth(Chibweshaetal.,2011).

• mothers living with HIV are fully adherent to theirmedications (Shapiro et al., 2010; Ngoma et al.,2011).

• mothers living with HIV breastfeed their babiesexclusivelyforthefirstsixmonthsoflife(seeTable1)(Morrisonetal.,2011).

When to start ART in pregnant and breastfeeding womenARTshouldbeinitiatedinALLpregnantandbreastfeedingwomen and continued for life on diagnosis of HIVinfection(WHO,2016c).

long-term antiretroviral interventions and exclusive and continued breastfeeding (ART+ebF)In recent years, significant programmatic experienceandresearchontheuseofantiretroviralregimens(ART)hasaccumulated.WhereverARTisroutinelyavailable,


ratesofverticaltransmissionofHIVhavebeenreducedbybetween1to2%(Townsendetal.,2008a).

The full effectiveness of ART in reducing maternalviral load to undetectable, thus preventing verticaltransmission during labour and birth, is achieved byensuring maternal adherence to ART for at least 13weekspriortodelivery(Chibweshaetal.,2011).

Theresultsfromthe8studiesoutlinedinTable1showthattheriskofpostnataltransmissionduringtheperiod

References Duration of Exclusive Breastfeeding

Antiretroviral treatment and/or prophylaxis Postnatal transmission

Determined by first infant HIV-positive test result period

Palombi et al. (2007)

6 months Maternal HAART from 25 weeks gestation until weaning; infant sdNVP after birth

0.8% (2/251) 1 - 6 months

Kilewo et al. (2008)

18 weeks Maternal ZDV & 3TC from ~34 weeks gestation to 1 week postpartum; infant ZDV & 3TC from 0-1 week, then 3TC alone during breastfeeding

1% (4/398) 6 weeks - 6 months

Kilewo et ak. (2009)

maximum of 6 months Maternal HAART from 34 weeks gestation to 6 months postpartum; infant ZDV & 3TC to 1 week of age

0.9% (4/441) 6 weeks - 6 months

Marazzi et al. (2009)

6 months; mothers advised to start weaning by 6 months ending within 2 months, but likely some breastfeeding 6-12 months;

Maternal HAART from 15 weeks gestation to 2 months post weaning; infant sdNVP after birth + AZT for 1 week

0.6% (2/341)

0.6% (2/239)

6 weeks - 6 months

6-12 months

Peltier et al. (2009)

6 months; mothers advised to wean at 6 months;

Maternal HAART from 28 weeks gestation to 7months postpartum; infant sdNVP after birth + ZDV for 1 week

0.44% (1/227)

6 weeks - 9 months

Shapiro et al. (2010)

EBF for 93% of infants to weaning: 71% breastfed >5months; <1% >6 months

Randomised and varied HAART regimens for mothers from 18-34 weeks gestation until weaning; all mothers also received supplemental AZT during labor: infant sdNVP after delivery plus 1 months AZT

0.3% (2/709) 1 - 6 months

Homsy et al. (2010)

EBF for 92% for 4 months, weaned at 5 months

Maternal FDC, median duration 5.2 - 20.3 months preceding delivery and during breastfeeding: infant sdNVP post birth or sdNVP + ZDV 1 week

0% (0/109) 6 weeks of age - 6 weeks postweaning

Thomas et al. (2011)

6 months Maternal HAART from 34 weeks gestation to 6 months postpartum: infant sdNVP at birth

0.8% (4/487) 6 weeks - 6 months

ofexclusivebreastfeedingcanbereducedto0to1%when:• mothers and/or their babies receive appropriate

ARVsfromearly/mid-pregnancyandthroughoutthebreastfeedingperiod.

• breastfeedingisexclusiveforuptosixmonths.

StudiesofpostnatalHIVtransmissionrates<1%at6months(inclusioncriteria:motherorchildreceivedARTandinfantswere exclusively breastfed). Breastfeeding-associatedtransmission was defined as excluding transmissiondiagnosedduringthefirstmonthpostpartum.

TAble 1: Risk of postnatal transmission with maternal ART and exclusive breastfeeding

Source:Morrisonetal.(2011)

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Continued mixed breastfeeding after 6 months + maternal ARTTwo Zambian studies (Ngoma et al., 2011; Gartlandet al., 2013) showed that where maternal HAART wasinitiatedduringpregnancyandcontinuedthroughoutbreastfeedingfor12months,HIVtransmissionduringcomplementaryfeedingorpartialbreastfeedingafter6monthscouldbereducedto1%.Furtherresearchshowsthatbreastfeedingcansafelycontinueto24monthsorlonger(WHO&UNICEF,2016).

Inthefirststudy(Ngomaetal.,2011)ARTwasinitiatedbetween14and30weeksgestation,andcontinuedto12monthspostpartum.Wheninfantswereexclusivelybreastfed to 6 months and continued breastfeedingwith complementary foods to 12 months, the risk oftransmission of HIV from 6 weeks to 12 months was1.1%.

In the second study (Gartland et al., 2013), wheremothers had received ART from pregnancy untilcessation of breastfeeding, infant HIV infection at 12monthspostpartumwas1%comparedtoatransmissionrateof12.1%forinfantswhosemothersreceivedonlyantenatalZDVandperipartumNVP,thestandardofcareatthetime.

Thus,considerationofvariousstrategiesemployedtoimprove overall child survival as well as protect thehealthofmothersrevealsthatthesafestistobreastfeedwithART,asshowninFigure2.

FIGURe 2: HIV-free survival, different ART regimens and feeding methods

Sources:Shapiroetal.(2010),Dunnetal.(1992),Nduatietal.(2000),DeCocketal.(2000),Coutsoudisetal.(1999),

Coutsoudisetal.(2001),Iliffetal.(2005),Thioretal.(2006),Townsendetal.(2008b).

BF + no ART

No ART + EBF

ART + no BF

ART + EBF

White babies Uninfected by any route

Blue babies HIV-infected through pregnancy and birth

Red babies HIV-infected through breastfeeding

Black babies Babies who die from causes other than HIV

“Effective use of antiretroviral drugs can now reduce transmission to such low levels that there are few circumstances in developing countries where artificial feeding can be justified.”

Source:WHOetal.(2010)

4.3 Continued Breastfeeding and Weaning

duration of breastfeeding

Inthesecondsixmonthsoflife,theongoingpossibleriskoftransmissionofHIVthroughbreastfeedingbyanuntreated mother living with HIV is less than 1% permonth.Thisneedstobeweighedagainstthegreaterriskofinfantdeathfromotherinfectionsandmalnutritionwhenachildisnotbreastfed.

recommendation on breastfeeding duration in the context of HiVWhen the mother continues to receive, and takes,appropriate ARVs beyond six months (lifelong ART),thentheriskofHIVcontinuestobealmostnegligible(Morrisonetal.,2011;Ngomaetal.,2011;Ngomaetal.,2015).TheWHOGuidelines(2010and2016)proposethatmothersknowntobeHIV-infected(andwhoseinfantsare HIV uninfected or of unknown HIV status) should


continuebreastfeedingforthefirst24monthsoflifeorlonger(WHO&UNICEF,2016).

A study from 2013 shows that changes in frequencyof breastfeeding before cessation of breastfeedingandwithnon-exclusivebreastfeedinginfluencedmilkviral concentrations.This may explain the reducedrisk of HIV-1 transmission associated with exclusivebreastfeedingandwhyearlyweaningdoesnotachievethemagnitudeofHIVpreventionpredictedbymodels.This possibility supports the rationale of continuingmaternalantiretroviraldruginterventionsoverthefulldurationof timewhenanybreastmilkexposuresmayoccur after planned cessation of breastfeeding (Kuhnetal.,2013).

Partial feeding after 6 monthsStudies on the low risk of HIV transmission when awomanreceivesandadherestoappropriateART• Concerns have been expressed about the risk of

HIV transmission during mixed feeding after 6months. However, recent research suggests thatwhen mothers living with HIV continue to receiveadequateARTfrom6to24months,thentheriskofHIV transmission to the baby in this period is alsoverylowat1to1.1%(Ngomaetal.,2011;Gartlandetal.,2013;Ngomaetal.,2015).

• Revisedrecommendationtocontinuebreastfeedingpast six months (WHO & UNICEF, 2016) are basedon the results of several important trials whichdemonstratethatmotherslivingwithHIVandonARTcanbreastfeedforlongerdurationswithonlysmallincreasesinpostnataltransmissionratesandthatthiscanbelife-savingfortheirinfants.Thebestavailableevidencesuggeststhattherisksofinfantsdyingfromotherdiseasesifbreastfeedingstopsprematurelyaregreaterthanthepotentialside-effectsofprolongedexposuretomaternalART.

• ContinuedmaternalARTallowstheinfanttoreceivethemaximumbenefitofbreastfeedingto improvethe infant‘s chance of survival while reducing therisk of HIV transmission. In the presence of ARVinterventions,beingabletobreastfeedforupto24monthsorlongeravoidsmanyofthedifficultiesduetostoppingbreastfeeding, includingtheprovisionofasafeandadequatedietwithoutbreastmilk.ThusARVsthatreducetheriskofHIVtransmissionthroughbreastfeedinghaveshiftedtherisk/benefitanalysisinfavourofbreastfeeding.

FIGURe 3: Rates of diarrhoea-related hospital admission or death among HIV-exposed uninfected infants by actual breastfeeding practice and by age

Even

ts pe

r yea

r of f

ollow

-up

0.35 -

0.30 -

0.25 -

0.20 -

0.15 -

0.10 -

0.05 -

0 -

Time period (months)

4-6 7-12 13-18 19-24

p=0.02

p=0.2

p=0.003

Stopped breastfeeding

Still breastfeeding

Source:Fawzyetal.(2011)

Breastfeeding with complementary foods after 6 monthsAllchildrenbetween6to24monthsorbeyond,needsafeandadequatecomplementaryfeeding.Breastmilkcontinuestohelpmeetachild’snutrientneeds foratleast2years.Whiletheamountofbreastmilkamotherproducesisnotdeterminedbythebaby’sagebutbyhisorhersucklingpattern,typically,breastmilkcanprovidethefollowingpercentageofenergyneedsattherelevantages(Williams,2003).SeeFigure4fordetails.

FIGURe 4: energy required by age and the amount from breastmilk

Ener

gy (K

cal/d

ay)

1200 -

1000 -

800 -

600 -

400 -

200 -

0 -

Age (months)0-2 m 3.5 m 6-8 m 9-11 m

Energy from breastmilk Energy gap

Source:WHO(2009b)

12-23 m

11



Breastfeedingintothesecondyearoflifereducesinfantmorbidity and mortality. For instance, breastfeedingpreventshalfof infantdeathsdueto infectionfrom6to23months.Breastfeedingforupto2yearsorbeyondalso protects against otitis media. In addition, longerduration of breastfeeding decreases the risk of infantoverweight or obesity and breastfeeding durationis directly associated with elevated IQ (Victora et al.,2016).

recommendation on weaning in the context of HiVWhenthemotherstopsbreastfeeding,sheshoulddososlowlyovera4-weekperiod.Abruptorrapidcessationofbreastfeedingisnolongergenerallyrecommendedat any time because it can cause painful breastengorgementandmastitisforthemotheranddistressfortheinfantoryoungchildandmayresultinelevatedvirallevelsinhermilk(Kuhnetal.,2013).

If therearedoubtsaboutmaternaladherencetoART,ithasbeenpostulatedthatdirectlytreatingtheinfantduring the risky period of mixed feeding prior to fullweaningmaybethemosteffectivemeansforpreventingtransmission of HIV during this vulnerable period(Doroskoetal.,2012).Anothereffectiveapproachwouldbetoexpressandheattreatmilkduringtheweaning(cessationofbreastfeeding)period.

Recommendation and guidance on breastfeeding for HIV infected childrenHIV-infected children can continue breastfeeding forupto2yearsorlonger,asbreastfeedingincreasestheirchancesofsurvival(WHO&UNICEF,2007).

The risk of HIV transmission through premastication of foodLittle attention has been given to the possibility thatpremasticationofweaningfoodsforyoungchildrenbymotherslivingwithHIVorothercare-giverscouldbeacauseoftransmissionofHIV.

Isolatedreportshaveconfirmedpremasticationoffoodas a route of infection of children, and it is possiblethat the risk of vertical HIV transmission throughbreastfeeding,particularlylatetransmission,hasbeeninflatedduetounder-reportingofinfectionviathisroute(CDC,2011b;Labrañaetal.,2013).

Public health officials and healthcare providersshould educate the public about the risk for diseasetransmissionviapremasticationandadviseHIV-infectedcaregiversagainstthepractice.

4.4 Positioning and attaCHment at tHe Breast

Key Points to enable attachment

Good positioning helps maintain correct attachment.Thebabyshouldbepositionedwith:w head and body in a straight line, neck slightly

extended.w nose/upperlipoppositethemother’snipple,facing

herbreast.w wholebodysupported(foranewbornbaby),with

nopressureonbackofbaby’shead.w bodyheldclosetothemother.

Therearemanydifferentpositions.Onepositionwillnotnecessarily work well for all mothers, because mothershavearmsofdifferentlengthsandbreastsofdifferentsizesandheights.Themotherneedstobewellsupportedandcomfortablesothatshecanholdherbabyclosetoherbreastandrelaxwithoutstraininganymuscles.

ThesearethemainpointsforattachmentandpositioningspecifiedfrombookletformothersbyBFF2008:w Startwithnoseoppositenipple.w Move the baby’s mouth across nipple until mouth

openswide,tonguedown.w Bring the baby quickly to breast–place the baby’s

chinonthebreastwithnoseatnipplelevelandthiswilltriggerthebaby’smouthtoopenwide.

signs of good attachment• Moreareolavisibleabovebaby’smouththanbelow.• Baby’smouthwideopen.• Lowerlipturnedoutwards.• Chinclosetobreast.• Motherfeelsnopain.• Babysuckleseffectively

– afewquickinitial“call-up”sucks,– thenslowdeepsucks,sometimespausing.

• Cheeksround.

signs of poor attachment• More areola visible below baby’s mouth, or same

aboveandbelow.• Mouthnotwideopen.• Lowerlipturnsinwardsorpointsforwards.• Chinawayfrombreast.• Motherfeelspainormarkeddiscomfort.• Rapidsucksthroughoutfeed.• Indrawingofcheeks.


4.5 exPressed BreastmilK and storage

Benefits of expressing breastmilk

Skilled health and community workers should knowhowtoshowmothershowtoexpresstheirbreastmilk.Expressingcanbeausefultechnique:w To avoid postpartum breast over-fullness which, if

leftuntreated,mayleadtoincreasedlevelsofHIVinbreastmilk(Semrauetal.,2011;Kuhnetal.,2013),andimpactsnegativelyonthemother’sfuturebreastmilksupply.

w To complete breast emptying for a sleepy baby(especiallyanewborn)andoffermoremilkbycupand/orassistwithincreasingmilksupply.

w Toprovideadequatemilkforababywhoisprematureorwhohasneurological impairmentorcongenitalabnormalities (e.g. Down Syndrome or cleft lip/palate)andisnotyetbreastfeedingeffectively,e.g.whocannotlatch,orstayattachedtothebreast.

w To provide expressed milk using cup-feeding ifbreastfeeding needs to be interrupted due toseparation(egforworkorseriousmaternalorinfantillnessprecludingbreastfeedingorifbreastfeedingistoopainful(egabradednipples)orifthemotherneedstodrainherbreastsduetoinfectiousmastitis,breastabscess.

w Tostimulateadwindlingmilksupplyortreatabreastcondition(e.g.pluggedductsandmastitis).

w Touseforheat-treating.

How to express breastmilk by hand

Themotherneedsto(WHO,2009c):w Have a clean, dry, wide-necked container with a

screw-capfortheexpressedbreastmilk.w Washhandsthoroughly.w Sitorstandcomfortablyandholdthecleancontainer

undernippleandareola.w Cupthebreastwiththethumbontopofherbreast

and her index finger underneath so that they areoppositeeachother,about4cmfromthetipofthenipple.

w Compress the breast tissue between fingers andthumb,pushingbackintothechestwall,andthensqueezingthethumbandfingersgentlytogethertoexpressthemilk,beforereleasingandrepeatingthisback-squeeze-release motion. After several breastcompressionsmilkstarts todriporspray fromthebreast.

w If milk does not appear, re-position thumb andfingeralittlecloserorfurtherawayfromthenippleand compress and release a number of times asmentionedbefore.

w Avoid rubbing or sliding fingers along the skinor squeezing or pinching the nipple itself. Hand-expressingshouldnothurt–ifitdoes,thetechniqueiswrong.

w Whentheflowofmilkslows,themothershouldmoveher fingers around the nipple/areola, in order tocontinueexpressingdifferentmilk-producinglobesofbreasttissueandcanusegentlemassagepriortoexpressingtoincrease/re-stimulatemilkflow.

w Expresseachbreastuntilthemilkdripsslowly(milkwillappearcreamywhenthebreastiswelldrained).Express each breast several times until there isenoughmilkforthebabyanduntilbothbreastsaresoftandcomfortable.

w Avoid the presence of domestic animals whenexpressingbreastmilk

FIGURe 5: expressing breastmilk by hand

Source:www.realbabymilk.org

13



guidance for storage of expressed breastmilk

w Freshly expressed breastmilk should be stored incoveredjar,e.g.jam-jarwithaplasticcap.

w Forreasonsofsafety,cup-feedingisrecommendedover bottle-feeding. Jars for storing breastmilk,cupsandspoonsforfeedingshouldbewashedandcleanedproperly,butneednotbesterilised.

w Shouldbestoredawayfromotherfood,especiallyrawmeat,alternativelythecontainercouldbeplacedinsideaplasticbagintherefrigeratororfreezer.

w Shouldbestoredinitsjarinaverticalposition.w Shouldnotbestoredinthedooroftherefrigerator,as

thetemperaturecanbealteredbyfrequentopeningofthedoor.

w Previously frozen and thawed breastmilk may bestoredintherefrigeratorfor12hoursbeforebeingused(ANVISA,2008).

w FreshbreastmilkcanbesafelystoredasexplainedinTable2.

TAble 2: Temperature and maximum recommended storage duration of fresh breastmilk in room temperature, refrigerator and freezer according to clinical protocol 2017

Location of storage

Temperature Maximum recommended storage and duration

Room temperature

16 – 29° C (60 – 85°F)

4 hours optimal6 – 8 hours acceptable under very clean conditions

Refrigerator ~ 4°C (39.2°F)

4 hours optimal6 – 8 hours acceptable under very clean conditions

Freezer < -4°C (24.8°F)

6 months optimal12 months acceptable

Source:Eglashetal.(2017)

alternative practices utilising breastmilk

Pasteurisation of banked human milkPasteurisedhumanmilk isavailableinmanyneonatalintensive care units. It is mainly used for prematurebabies in small quantities and has a lower risk ofnecrotizing enterocolitis compared to infant formula(Naickeretal.,2015).ItistypicallypasteurisedbyHolderpasteurisation, i.e. heated to 62.5 °C /144.5 °F for 30minutes,inordertoinactivatecommunicablepathogens

includingHIV(Orloffetal.,1993).Thismethodisroutinelyusedbyhumanmilkbanks.Themilkisheatedto62.5°Cfor30minutes(Orloffetal.,1993).Bankedmilk, ifavailable, issuitableforfeedingHIV-exposedbabies.

Thehigh-temperatureshorttime(HTST)pasteurisationprocess (72°C for 16 seconds) is also effective in theeliminationofbacteriaaswellasofcertainimportantpathogenicvirusesincludingHIV.OneexampleofHTSTistheFlash-heatingmethodusedinHumanMilkBankinginSouthAfricai.e.,heatinghumanmilkat72°C(high-temperature,short-time)(PATH,2011).Foracomparisonbetween Holder Pasteurisation and Flash-heating seeTable3.

TAble 3: The figure from the PATH 2015 shows the comparison among Holder Pasteurisation and Flash-heating Pasteurisation considering % retention of key human milk components

Milk component HolderPasteurisation

Flash-heating

LactoferinIron-binding protein that has antimicrobial and antiviral properties

44% 100%

Immuniglobulin AMajor antibody that protects against pathogens

80 – 100% 80%

LysozymeEnzyme with antimicrobial properties

75 – 100% 74%

Thiamine, folic acid Vitamins important for neurological development

100% 100%

Source:PATH(2011)

FIGURe 6: The figure from the PATH 2015 summarises safe-guarding quality of post-pasteurisation procedures at Human Milk banking

Source:PATH(2011)

Safe-guarding quality at the Milk BankPost-pasteurization procedures• Sample are tested regularly

for bacterial contamination• Donor pasteurized milk stored

at -18°C for up to 6 months• Pre-term infants, breast milk

stored for only 3 months.

1� U n d e r s t a n d i n g I n t e r n a t i o n a l Po l i c y o n H I V a n d B r e a s t f e e d i n g : a c o m p r e h e n s i v e r e s o u r c e

Pasteurisationathumanmilkbankforfull-termandolderbabiesofmotherslivingwithHIVisnotusuallyavailabledue to fears of contamination within the milk bank.However,thisserviceisknowntobeavailableinahumanmilk bank in Sao Paulo, Brazil for milk from mothersofHIV-exposedbabies (DaSilva,2004).Fordetailsonhow to safe-guard the quality of post-pasteurisationproceduresathumanmilkbankseeFigure6.

Feasibility of human milk banking in the HIV contextStigmatisationiscommonamonghealthprofessionalsandthegeneralpublic,relatedtosafetyofpasteurisedhuman milk. Such concern arises due to fear oftransmission of infection through donors’ breastmilkandlackofawarenessonhumanmilkbank,consideringalso the benefits of Human Milk Banking as the firstchoice for preterm infant feeding (Arslanoglu et al.,2013), including for infant survival in developed anddevelopingcountries.

In settings with high HIV prevalence the fear oftransmissionofHIVfrompasteurisedmilkisincreaseddue to cultural, and religious non-acceptability andlackofknowledgebyhealthprofessionalsofthesafetyofbankedpasteurisedhumanmilk (Coutsoudisetal.,2011).However,thestudyfindingsofCoutsoudisetal.(2011)fromapublichospitalinDurbaninSouthAfrica,showsthefeasibilityofsupplyingpasteuriseddonormilkataNeonatalPrematureUnit,reinforcingtheimportanceof HIV exposed preterm infants receiving milk from aHuman Milk Bank rather than infant formula that is asourceofallergensandcontaminantsthatcouldincreasetheriskofHIVtransmission.

Fromaquantitativecross-sectionalstudyataNigerianteaching hospital, looking at women’s perceptionsof using pasteurised human milk, the study findingssuggestedthat51%ofwomenhaveheardaboutHumanMilkBankingbefore,butmostwomen(85%)wouldnotgivepasteuriseddonormilktotheirinfants,duetofearoftransmissionofinfectiousdisease.Ontheotherhand,the same study result shows 59.1% of women wouldconsiderHumanMilkBankingasasupportformother’sinneed(Alemu,2016).

According to the European Society for PaediatricGastroenterology,Hepatology,andNutrition,donatedhumanmilkisassociatedwithalowerriskofNecrotizingEnterocolitisincomparisontoinfantformula.AppropriatehumanmilkpasteurisationismicrobiologicallysafeandHumanMilkBankingcancontributetodecreasedinfant

formulauseduringthefirstweeksoflife(Arslanogluetal.,2013).

Heat-treatment of mother’s own expressed milkHeat-treatedexpressedbreastmilkisasafealternativetobreastfeeding.MotherslivingwithHIVandwhochoosenottobreastfeedbecauseoftheriskofHIVtransmissiontotheirinfantswouldbewellservedifthepossibilityofusingtheirownheat-treatedexpressedbreastmilkcouldbemadepossible.Thereseemsnogoodreasonwhyitcannotbearealisticoptioninthenearfuture.Clearly,feeding expressed breastmilk is far more superior toinfantformula,theproductislocallymanufactured,theprocedurewillhavebenefitstothemother’shealthandwillreduceherlikelihoodofanearlypregnancy(Latham&Kisanga,2001).

Home pasteurisationChantr y et al . (2000) have shown that home -pasteurisationmethodscaninactivateHIVinbreastmilk.Itispossibleformotherstoexpresstheirbreastmilkandheat-treatitusingsimplemethodsathomesothattheycansafelyfeedittotheirbabiesandthuseliminateallriskofpostnataltransmission(Youngetal.,2011).

Research shows that flash-heating is a safe methodof home-pasteurisation. Flash-heat retains theantibacterial activity in breastmilk and may be ofparticular value during times of greater risk forpostnataltransmissionofHIV,suchasduringepisodesof infantoralthrush,maternalmastitis,or interruptedantiretroviral prophylaxis and/or during weaning(Chantryetal.,2011).

Guidance on safe methods of home-pasteurisationFlash-heating is a somewhat superior methodto inactivate viral activity, compared to Pretoriapasteurisation,andretainsmorenutrients(Israel-Ballardet al., 2005; Israel-Ballard et al., 2006b).These are theproceduresforbothmethods:

A. Pretoria pasteurisation(Jefferyetal.,2001;Israel-Ballardetal.,2005;Israel-Ballardetal.,2006b)

• Place50mlto150mlbreastmilkintoacleanglassjarandcover.

• Boil 450ml water in a small aluminium pot, andremovefromtheheat-source.

• Placecoveredmilkjaruprightinthepanofboiledwater,coverthepanandleavefor15to20minutesbeforeremoving.Milkmaybefedtothebabyoncecooled.

15



• previouslyheat-treatedbreastmilkcanbestoredfor12hoursatroomtemperature,inanunopenedjar.

B. flash-heating (Israel-Ballard et al., 2005; Israel-Ballardetal.,2006b;Israel-Ballard,2007;Israel-Ballardetal.,2007;Israel-Ballardetal.,2008a)

• place50mlto150mlmilkinacleancovered450mlglassjar.

• placethejaruprightinasmallpanofcoldwater.thelevelofwaterinthepanshouldbetwofinger-widthsabovethelevelofthemilkinthejar.

• place the pan on the stove over high heat untilthe water reaches a rolling boil–this helps topreventoverheatinganddamagetomother’smilknutrients.

• removethepan fromtheheatandremovethe jarfromthehotwater.

• putthelidonthejar,andcoolthemilkbeforefeedingtothebaby.

• previouslyheat-treatedbreastmilkcanbestoredfor8hours,roomtemperature(23oC).

Re-heatingpreviouslyheat-treatedbreastmilkthathasbeenrefrigeratedisgenerallyunnecessaryforhealthytermbabies.

Ifyouprefertowarmthemilk,youcanplacethecoveredjarinapotofhotwater(whichisnolongeronthestove)andgentlyswirluntilthemilkiswarm.Pourthemilkintoacleancupandtestthatitisroughlybodytemperature(warmbutnothot),beforeofferingittothebaby

Benefits of receiving the heat-treated breastmilk of a mother living with HiV to the baby

Benefitsofheat-treatedexpressedbreastmilkw physiologicallynormalandnon-allergenic.w nutritionally adequate (some components slightly

changed)(Israel-Ballardetal.,2008b).w inactivates HIV and bacteria (Israel-Ballard et al.,

2006a;Israel-Ballardetal.,2007).w afreeandfeasibleinfantfeedingmethod(Sibekoet

al.,2008;Chantryetal.,2012).w retains some immunological protection (Israel-

Ballard et al., 2006a; Israel-Ballard et al., 2008b;Chantryetal.,2009).

w likely to maintain a normal maternal postpartumhormonalprofile,to.• promotematernal-infantbonding.• facilitate lactational amenorrhea/reduced

fertility.

w the supply / sustainability / baby’s foodsecurityremainswithinthemother’scontrol(Gashumbaetal.,2010;Mbuyaetal.,2010).

w canbesafelystoredafterpasteurisationfor8hoursatroomtemperature(Israel-Ballardetal.,2006a).

w causesnoriskofHIVtransmissionifusedasamixedfeedingmethod,sinceHIVisinactivated.

w can be used from birth, or may be particularlyvaluable as a short-term feeding strategy duringtimesofhighrisksuchas:• Ifthebabyislowbirthweightorsickandunable

tobreastfeed.• Iftheinfanthasoralthrush.• Ifthemotherhasmastitis,ordamaged/abraded

nipples.• Toassistmotherstoceasebreastfeeding.• IfARVsaretemporarilyunavailable.• IfthemotherisawaitingHIVtestresults.

4.6 tyPes of alternatiVe feeding metHods

Cup-feeding

Therearesomesituationsinwhichthebabymaynotbeabletofeedfromthemother’sbreast.Cup-feedingmaybeappropriateinthesesituationsas:w babydoesnotneedtosuck.w encouragesrhythmicmovementsofbaby’stongue

andjaw.w babypacesitsownfeed.w babytakeswhatitwants.w babyisheldcloseduringfeed.w no danger of aspiration, and very safe if properly

done.

Some characteristics of cups for feeding newbornbabiesw cancontain50to90mlofmilk.w glassorplasticandeasilywashable.w smooth/roundededge.w withalidforstoringexpressedbreastmilk.

Howtoofferfreshbreastmilkusingcup-feeding(WHO&UNICEF,1993)Step1 Thecaregivershouldwashherhandswithsoap

anddrythem.Step2 Thecaregivershouldholdthebabycomfortably

on her lap in an upright or semi-uprightposition.


Step3 The caregiver should gently hold the cup tothebaby’slips,placingtherimofthecuponitslowerlip,withtheedgeofthecupjusttouchingpartofthebaby’supperlip.

Step4 Thecaregivershouldletafulltermbabyorolderbabytodrawthefreshmilkfromthecupusingthetongue,spillingsomeofit.

Step5 The caregiver should not pour the fresh milkintothebaby’smouth,butgentlyholdthecuptoitsbaby’slipsandletittakethemilkonitsown.

Step6 Thebabywillcloseitsmouthandrefusetotakeanymorewhenithashadenough.

Step7 Themorethecaregiverandbabypracticewiththecup,theeasieritwillbecome.

Step8 In theevent that thebabydoesnot take theexpectedamountatanyonefeeding,itislikelythatitwilltakemoreatthenextfeeding.

Step9 Trytomeasurebaby’sintakeper12or24hoursratherthanateachfeed.

droppers

w Idealforsmallamounts.w Canbeusedtodropbreastmilkontothemother’s

areolaornippleforthebabytolick.w Difficulttoclean.

syringe-feeding

w Idealforsmallamountsofbreastmilke.gcolostrum.w Makesuseoflinguallipases.w Avoidstheneedtosuck.w The baby must be able to co-ordinate swallowing

andbreathing.w Thebabyisnotincontrolofpaceoffeedorbolus

size.w Milkshouldbeputintothesideofthemouthorjust

underthetongue.w Difficulttoclean.

Syringescanbeusedto:w dropbreastmilkontotheareolaornippleforababy

tolick.w storecolostrumuntilitcanbegiventoababy.

spoon-feeding

w idealforsemi-solids.w idealforexpressedcolostrumif:

• babyishypoglycaemic.• motherisunwell.

• infantnotyetsucklingwell.w babynotincontrolofthebolussizeorpaceofthe

feed.

4.7 mixed feeding and rePlaCement feeding

mixed feeding before 6 months of age

Mixed feeding before 6 months should be stronglydiscouragedbecause:w itposesthesamerisksofcontaminationasartificial

feeding, increasing the risk of HIV-transmission,diarrhoea,pneumonia,malnutritionanddiminishingthechancesofsurvival(Kuhnetal.,2007).

w replacing breastmilk with other foods leads tocompromised breastmilk supply (Lawrence &Lawrence,1999;Riordan&Auerbach,1999).

AccordingtothelastWHO2016recommendation,mixedfeedingisnotareasontostopbreastfeeding(WHO&UNICEF,2016).

MotherslivingwithHIVaswellashealth-careworkerscanbeassuredthat:w ARV treatment reduces the risk of postnatal HIV

transmission in the context of mixed feeding.Althoughexclusivebreastfeedingisrecommended,practicing mixed feeding is not a reason to stopbreastfeedinginthepresenceofARVdrugs.

w a short period of breastfeeding of less than 12monthsisbetterthanneverinitiatingbreastfeedingatall(WHO&UNICEF,2016).

Whilewomeninmostlow-incomecountriesbreastfeed,theratesofexclusivebreastfeedingarelow,particularlyinAfrica(thoughtheyareincreasingtherenowmorethanelsewhere).ThishasimplicationsforanincreasedriskofHIV-transmissioncomparedtoexclusivebreastfeeding(Kuhnetal.,2007;WHO&UNICEF,2016)dueto:w damage to infant gut as a result of exposure to

foreignpathogensinotherfoodsandliquids(solidfoodsmayposea4to10-foldgreaterhazardthanliquids)(Coovadiaetal.,2007;Lunneyetal.,2010).

w inflammation within the infant gut due to theintroduction of foreign antigens (Smith & Kuhn,2000).

w elevations in breastmilk viral load as a resultof decreased frequency of infant suckling and

17



consequentmilkstasis(breastengorgement)(Kuhnetal.,2013).

w epithelial permeability or increase in leaky tightjunctions in the breast allowing more efficientparacellulartransferofcell-freeandcell-associatedHIVintobreastmilk(Kourtisetal.,2003).

w irregularversusregularmilkremoval,i.e.occasionallong intervals between breastfeeds, or shifts inbreastfeeding frequency, leading to elevated viralloadinbreastmilk(Smith&Kuhn,2000).

w infrequentbreastfeedingmayalsoresultinelevatedbreastmilksodium,andorsubsequentmastitis,alsoknowntobeariskfactorforHIVtransmission(Sembaetal.,1999b).

Figure 7 shows how the combined effect of mixedbreastfeedingbothontheinfantgut(infantsusceptibility)and on the mother’s milk production and milk viralload (maternal infectivity) exacerbate the risk of HIVtransmissionduringbirthto6monthperiod.

FIGURe 7: Combined effect of mixed breastfeeding on mother and baby

Source:Morrison(2010)

Increased risk with mixed feeding 0-6 monthsHow it works

Breastmilk and other foods / liquids containing foreign

pathogens and antigens

Displacement ofbreastmilk milk

stasis breast permeability,elevated sodium mastitis

Infant gut damage and inflamation

Contact between virus and infant’s

bloodstream

Elevated viral levels in milk

recommendation for the risk of replacement feedingFormostofthedevelopingworld,therisksofincreasedmorbidity,mortalityandmalnutritionduetoreplacementfeeding exceed the risks of HIV-transmission due tobreastfeeding,especiallywhenbreastfeedingisexclusiveinthefirstsixmonthsoflifeandwhenappropriateARVs

are provided. WHO suggests that mothersknown to be HIV-infected should only givecommercial infant formula as a replacementfeedtotheirHIV-uninfectedinfantsorinfantswhoareofunknownHIVstatuswhenspecificconditionsaremet(WHOetal.,2010).

Health outcomes due to formula-feeding, especially increases in overall rates of infant malnutrition, morbidity and mortality

Health outcomes for replacement feeding versus exclusive and continued breastfeeding in developing countriesDespite reductions in postnatal HIV-transmission,replacementfeedingbymotherslivingwithHIV,eitherfrombirth,orafterashortenedperiodofbreastfeeding,wasassociatedwith:w A47%higherriskofpneumoniacomparedtothose

never breastfed in Kenya during 1999 – 2002.Breastfeeding was also associated with a 74%lower risk of pneumonia-related hospitalisation(Ásbjörnsdóttiretal.,2013).

w Increased infant morbidity and mortality inprogrammaticsettingsinIndia(Phadkeetal.,2003;Alvarez-Uria et al., 2012), Malawi (Kafulafula et al.,2010;Jamiesonetal.,2012),SouthAfrica(Coovadiaetal.,2007;Dohertyetal.,2007),Uganda(Kagaayietal.,2008;Homsyetal.,2010;Onyango-Makumbietal.,2010)andBotswana(Thioretal.,2006;Creeketal.,2010).

w Extremelyhighinfantmortalityrates(217per1000livebirths)mostlyinthefirst6monthsoflifeinHaiti(Coutsoudisetal.,2008).

w Increased rates of malnutrition, serious infections,including pneumonia and diarrhoea, growthfaltering and death for uninfected infants whoavoidedpostnataltransmission(Nduatietal.,2000;Chopraetal.,2005;Manzietal.,2005;Arpadietal.,2009;Molandetal.,2010;Fawzyetal.,2011;Vågaetal.,2014).

w Increasedmorbidityandmortalityafterweaningwithearly cessation of breastfeeding.Though stoppingbreastfeedingafter4-6monthsreducesthelengthoftimethattheinfantisexposedtoHIVinbreastmilk,thereisincreasedmortalityafterweaningcomparedto continuing breastfeeding for the locally normalspanoftime(Kuhnetal.,2008;Kafulafulaetal.,2010;Kuhn et al., 2010; Onyango-Makumbi et al., 2010;Becquetetal.,2012).


Health outcomes for replacement feeding versus exclusive and continued breastfeeding in developed countriesIn developed and less developed countries, despitedifferent government policies on infant feeding andHIV, most women living with HIV are discouragedfrom breastfeeding and have further restrictions dueto inadequate support and weak counselling fromhealth system and fears of possible late HIV infectionoflactatingwomen(Blumentaletal.,2014).Evenso,indevelopedandlessdevelopedcountriestherisksofHIVmustbebalancedwiththebenefitsofbreastfeedingtowomenandinfantsandthepotentialrisksfor infant’sand women’s health as a result of artificial feeding(Stuebe,2009;Victoraetal.,2016),eg:• Theassociationofnotbreastfeedingwithinfection

morbidity,forinstance,otitismedia,gastroenteritisandpneumonia(Stuebe,2009;Victoraetal.,2016);

• The association of artificial feeding with non-communicablediseases,forexample,asthma,infantoverweightorobesity,andinfanttype1andtype2diabetes(Stuebe,2009;Victoraetal.,2016);

• Suddeninfantdeathsyndrome(SIDS)andchildhoodleukaemia are also associated with non-breastfedinfants(Stuebe,2009;Victoraetal.,2016);

• For the premature newborn, no breastfeedingis associated with an increased risk of neonatalnecrotizing enterocolitis (Stuebe, 2009;Victora etal.,2016);

• Breastfeeding is associated with less chance ofmalocclusions(Victoraetal.,2016);

• BreastfeedingisassociatedwithhigherIQinchildrenandadolescents,highereducationalattainmentandadultearning(Victoraetal.,2016);

• RiskofcontaminantssuchasCronobacter sakazakii in powdered infant formula or water used to mixpowderedinfantformula(Hardy,2016);

• No breastfeeding can be associated with negativehealth outcomes for women such as increasedincidenceofpremenopausalbreastcancer,ovariancancer, retained gestational weight gain, type 2diabetes,andmetabolicsyndrome(Blumentaletal.,2014).

exceptions to national one-policy recommendationMothers living with HIV who wish to replacementfeed in settings where the national policy supportsbreastfeeding should follow the new description ofconditionsneededforsafereplacementfeeding.

FormulafeedinghasnotbecomeanysaferasaresultofthediscoverythatHIVcouldbetransmittedthroughbreastfeeding.Mothersandfamiliesneedtobeinformedoftherisk(WHO,2009b).

new description of conditions needed for safe replacement feeding Mothers known to be HIV-infected should only givecommercialinfantformulaasareplacementfeedtotheiruninfectedinfantswhenallsixspecifiedconditionsaremet(WHO,2009b):• Safe water and sanitation are assured at the

householdlevelandinthecommunity,and• Themother,orothercaregivercanreliablyprovide

sufficient infant formula milk to support normalgrowthanddevelopmentoftheinfant,and

• Themotherorcaregivercanprepareitcleanlyandfrequentlyenoughsothatitissafeandcarriesalowriskofdiarrhoeaandmalnutrition,and

• Themotherorcaregivercan,inthefirstsixmonths,exclusivelygiveinfantformulamilk,and

• Thefamilyissupportiveofthispractice,and• Themotherorcaregivercanaccesshealthcarethat

offerscomprehensivechildhealthservices.

Non-breastfedinfantsshouldbeprovidedwithsafeandadequatereplacementfeeds,orheat-treated,expressedbreastmilk,toenablenormalgrowthanddevelopment.Replacementfeedingshouldonlybeundertakenwhenexplicitconditions regardingsafetyandsustainabilityare met. A simplified version of the“AFASS” concept(whetherreplacementfeedingwasacceptable,feasible,affordable,sustainableandsafe)wasdevelopedtomakeiteasierforhealthworkerstorecommendifreplacementfeedingwouldbeappropriate.

recommendation and guidance on replacement feeding with artificial milk• Formulafeedingrequiressufficientformulatofeed

the baby for the time that he would have beenbreastfed(40kgofpowderedinfantformulatofeedonebabyforoneyear).Thecaregivershouldbeableto follow directions regarding hygiene, measuringandmixingformulapowderandwatersufficientforthebaby’sneeds(150mlformulaperkgof infant’sweightperdaydividedinto8ormorefeeds).Recentlyboiled water should be mixed with the powderedformulamilkwhenitisstillhot(>70°C)tokillmicro-organismsinthewaterandharmfulbacteriawhicharesometimespresentinthemilkpowder(WHO&

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FAO,2007).Ifreplacementfeedingisusedinthefirstsix months for HIV-exposed babies, it must be fedexclusively–withnobreastfeedingatall–toavoidthe high risk of HIV transmission associated withprematuremixedfeeding(Coutsoudisetal.,2001).

• H o m e - m o d i f i e d a n i m a l m i l k i s n o l o n g e rrecommendedbytheWHOforreplacementfeeding,duetoconcernsaboutnutritionaladequacy(WHO,2006).Anexceptionwouldbefortheshortestpossibletimeinanemergencysettinguntilanothersourceofdonatedbreastmilkorcommercialinfantformulabecomesavailable.Thereissomeconcernthatthereisinsufficientevidencefortheserecommendation,andseveralcountriesarestillrecommendinganimalmilkasthefirstchoiceforreplacementfeeding. Inaddition,adviceagainsttheuseofanimalmilkonlyappliesduringthefirst12monthsoflife.

the criteria for safe replacement feeding in emergency settingsEmergenciessuchasconflicts,floods,earthquakes,firesand power supply failures can occur in both affluentandpoorcommunities.Refugees, internallydisplacedpopulations,asylum-seekersandhomelesspeople,areoften in situations where the criteria for replacementfeeding cannot be met (ICDC, 2009a). In unstablesituations,ARVsmaynotbeavailable,formuladonationsmay not be sustainable, water and fuel supplies maybe limited, and the risk of infection may be high.Under such conditions, breastfeeding of HIV-exposedinfantsisrecommendedtoincreasesurvival(WellstartInternational,2005;ENNetal.,2007;WHOetal.,2010).

Key information on infant formula or boiled animal milkNon-breastfed infants aged 6-12 months may receivecommercial infant formula or boiled animal milk, aspartofadietprovidingadequatemicronutrientintake,aslongashomeconditionsoutlinedabovearefulfilled.

Meals,includingmilk-onlyfeeds,otherfoods,and combinations of milk and other foods,should be provided 4-5 times per day (WHOetal.,2010).

Recommendation on cup-feedingCup-feeding is safer for feeding replacements thanbottle-feeding because cups are easier to clean thanbottles, and cup-feeding requires the mother’s fullattentionduringfeeding.

Wet-nursing is recommended in emergency settingsHowever, there may be concerns because of culturalandreligiousvalues.• In most cultures, the mother and the members of

themother’s familyonlyacceptwet-nursing if thewet-nursebelongstothesamefamily.

• ForMuslims,theKoranreferstobreastmilkaswhiteblood,thustheinfantbecomesabloodrelationtothewet-nurseafterfivesucklingepisodes.

• Jehovah’sWitnessesmayrefusethedonationoffreshbreastmilk in the same way as they refuse bloodtransfusions.

• This can be protective to the infant since it isimportanttoknowthewet-nursewell,includingherHIVstatus.

• Thewet-nursemayalsorequireHIVcounsellingtoreducetheriskofHIV-infection.

Recommendation for wet-nursing considering a review of evidences for transmission of HIV from children to breastfeeding women and implications for preventionWetnursesshouldbeawarethatHIVcanbetransmittedfromanHIV-infectedinfantviabreastfeeding(Littleetal.,2012)incaseoflackoffulladherenceoftheinfanttoART.Theyshouldbevigilanttoavoidbreastfeedingwhenthereiseitheranorallesionintheinfantorabreastlesionandinsuchcasesgiveexpressedbreastmilk.


TheWorldAllianceforBreastfeedingAction(WABA)isaglobalnetworkofindividualsandorganisationsconcernedwiththeprotection,promotionandsupportofbreastfeedingworldwide.WABAactionisbasedontheInnocentiDeclaration,theTenLinksforNurturingtheFutureandtheGlobalStrategyforInfant&YoungChildFeeding.WABAisinconsultativestatuswithUNICEFandanNGOinSpecialConsultativeStatuswiththeEconomicandSocialCounciloftheUnitedNations(ECOSOC).

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