Implications of infant feeding choice
Programmes for prevention of mother to child
transmission (MTCT) need to focus not only on
preventing HIV transmission but also on
improving child survival. Exclusive breastfeeding
has been identified as the single most effective
way of saving the lives of millions of young
children in developing countries1, a fact that is
supported by international policy2 and operational
guidance for emergency contexts3.
Although most infants in sub-Saharan Africa
are breastfed, rates of exclusive breastfeeding
are low as early introduction of liquids is a common
practice. It is against this background that
infant feeding recommendations for women
with HIV are being implemented. If women
with HIV are to succeed in practising exclusive
infant feeding, then improvements in infant
feeding practices in the general population are
necessary to ensure that exclusive breastfeeding
is the norm rather than an exception.
A recent study4 from South Africa has confirmed
earlier findings5 that exclusive breastfeeding
results in a lower rate of postnatal HIV
transmission compared to mixed feeding. This
study, undertaken in a rural area in KwaZulu-
Natal province, found a cumulative postnatal
HIV transmission risk of 4.04% after five
months of exclusive breastfeeding. Infants who
were fed both breast and formula milk at age
twelve weeks were twice as likely as exclusively
breastfed infants to be infected (HR 1.82, 95%
CI: 0.98-3.36).
Recent data from Mozambique6 and the ZVITAMBO
study in Zimbabwe7 have highlighted
the dangers of early cessation of breastfeeding
under conditions of underlying poor socio-economic
status and food insecurity. In
Mozambique, commonly consumed, locally
available foods would not meet the nutritional
needs of non-breastfed infants between 6-12
months of age and replacing breastmilk with
local foods would double the estimated daily
cost of feeding a 6-12 month infant. In
Zimbabwe, most of the infant diets only met
58% of the infants energy needs and were
insufficient in animal milks or formula.
Replacement feeding means feeding an infant a
diet that provides the necessary nutrients while
receiving no breastmilk. Recent research and
experiences from Botswana (see research summaries
in this issue of Field Exchange) highlight
the risks of formula feeding and reinforce the
importance of individual assessments of home
and environmental circumstances in the
process of decision-making. In low and middle
income countries and in emergency contexts,
replacement feeding is unlikely to be the most
appropriate choice for HIV positive women due
to socio-economic environments that are not
conducive to safe replacement feeding.
The importance of counselling
Given the implications that infant feeding
choice may have for child survival, infant feeding
counselling and support is one of the most
important components of PMTCT programmes.
In many countries, shortcomings in the
implementation of the WHO guidelines have
been found. Inadequate training of health
workers, particularly infant feeding counsellors,
about the relative risks associated with
infant feeding in the context of HIV, lack of culturally
sensitive counselling tools, and the stigma
associated with replacement feeding, all
make appropriate and effective infant feeding
counselling difficult.
Within the context of busy antenatal clinics,
it is not surprising that the quality of infant
feeding counselling has generally been found to
be poor.
One intervention that has been shown in a
variety of settings to increase exclusive breastfeeding
is peer counselling. Peer counselling is
a proven cost-effective approach for changing
behaviour. Community-based interventions
using local womens groups have also been
shown to change behaviour in relation to infant
feeding and birth outcomes. |
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