Session 5 - Infant Feeding

Technical/Scientific Update: Stephen Arpadi, MD, Pediatric Advisor for Nigeria, reviewed the latest research findings around infant feeding in the context of HIV and described the best infant feeding options for HIV-positive women and infants.  Stephen reviewed the importance of maternal health in infant feeding and the risks of replacement feeding and early weaning.  He presented scientific justification for the proposed ICAP approach to infant feeding and enhanced HIV-free survival of HIV exposed infants. 

ICAP approach: Fatima Tsiouris, MS, PMTCT Program Officer and Nutrition Advisor, proposed an ICAP approach for infant feeding, to be adopted and adapted by country programs, which included recommendations such as: avoidance of mixed feeding from birth to 6 months; avoidance of early cessation of breastfeeding; and avoidance of rapid weaning of breast milk or abrupt changes in breastfeeding frequency.  She reviewed current knowledge and practices around infant feeding counseling messages, available feeding options and challenges site staff are faced with at the following ICAP sites: Mozambique, Nigeria and Rwanda.

Issues raised during Question & Answer session:

  • If moms cannot do exclusive breastfeeding for 6 full months (they may need to return to work or have other logistical issues), then providers should encourage them to do it as long as is possible, 2 months, 3 months, etc.  Any increase in duration of EBF is of benefit.
  • WHO AFASS recommendations may feel inappropriate as a public health message if the majority of women cannot fulfill it.
  • Weaning is a dangerous time for infants, with higher rates of gastro-enteritis and other issues during this period.
  • The ZEBS study in Zambia found no benefit in HIV-free survival from early weaning (average length of breastfeeding for the study was 16 months in the late weaning group and 4 months in the early weaning group.).
  • If ARV drugs exist at low levels in breastmilk, the infant may risk developing resistance to those drugs.
  • Need to clearly differentiate between the terms “complementary feeding” and “mixed feeding”.  “Mixed feeding” is the introduction of foods or fluids other than breastmilk within the first 6 months, and is considered dangerous.  “Complementary feeding” indicates the addition of foods or fluids to a diet of breastmilk after the first 6 months of life, is necessary for proper nutrition and growth, and should not have a negative connotation.
  • We need to ensure that good complementary foods are available for when exclusive breastfeeding ends.
  • In families with real food scarcity, a mother may receive enough formula for the baby from a clinic, but may end up sharing the formula with the family because there isn’t enough food in the household.
  • Counseling for exclusive breastfeeding needs to start prior to birth, so that mothers-to-be can begin to think of ways to deal with a mother-in-law or other person bringing over teas or attempting to give the baby water.  The introduction of teas to promote health can actually encourage diarrhea.  This is complicated by the fact that sometimes the giving of water or tea to the baby happens while the mother is away (e.g. at the clinic) and a relative is taking care of the baby.
  • If an HIV-positive mother gets a breast infection, her viral load will increase.
  • We need to train providers to give consistent and appropriate messages.  “Mixed messages are as dangerous as mixed feeding.” In Ethiopia most mothers who decide to use formula do this on the recommendation of a health care provider.
  • Formula is safer than modified animal milk; avoid modified animal milk before 6 months of age.
  • Maternal nutrition is often an issue; many mothers do not have enough food and are unable to produce enough breastmilk.  Perhaps ICAP could provide multivitamin supplementation.
  • Diarrhea can result from mixed feeding, so it is important for providers to ask if children are having diarrhea before 6 months of age, and to ask about infant feeding choices.

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