[pronut-hiv] Early weaning by HIV-positive mothers needs to be accompanied by nutritional support for infant

["ProNut-HIV" <pronut-hiv@healthnet.org>]

Aidsmap- May 16, 2006
Early weaning by HIV-positive mothers needs to be accompanied by
nutritional support for infant 

Reseachers in Cote D'Ivoire have found that encouraging HIV-positive
mothers to cease exclusive breastfeeding altogether by the time their
children are six months old greatly increases the risk of stunted growth
unless mothers are able to introduce an adequate range of foods to
replace the nutritional value of breast milk. The findings, published in
the April edition of the journal Pediatrics, suggest that mother and
child health programmes which seek to promote exclusive breastfeeding as
a risk reduction strategy need to provide nutritional counselling at the
time of weaning and may need to provide nutritional support too. 

HIV-positive women who do not have access to clean water and formula
feed for their infant are advised in most resource-limited settings to
breastfeed exclusively and to attempt to wean the infant around six
months after birth. These recommendations are the result of several
clinical studies that have shown: 

Exclusive breastfeeding carries a lower risk of mother to child HIV
transmission than `mixed` feeding, where infants are breastfed but also
receive water and other foods.

The risk of HIV transmission through breastfeeding remains relatively
constant after day 28 of breastfeeding, so the longer the breastfeeding
period lasts, the higher the risk of HIV transmission.

However early weaning may be counter-productive for the child if breast
milk is replaced by poor food sources with a limited range of nutrients,
leaving children open to poor growth and infections. 

Researchers associated with the DITRAME Plus study in Cote d'Ivoire
wanted to find out whether children who were weaned early, following
these recommendations, were poorly nourished or at a growth
disadvantage. The study did not look at child mortality or morbidity. 

Two hundred and sixty HIV-positive mothers were questioned weekly until
their children were nine months old (and quarterly thereafter) about
what food their children had received in the previous day and the
previous week. At each visit infants were classified as exclusively
breastfed, predominantly breast fed, mixed fed or formula fed (follow
this link for explanations of each of these definitions). 

Mothers were taught how to breast-feed correctly and group sessions
explained the benefits of exclusive breastfeeding, how to initiate
weaning and what foods should be introduced at the time of weaning. 

The researchers developed a numerical index which gave points for
positive nutrititional practices, including the diversity of foods which
infants received after weaning and the frequency of meals containing
various food groups. 

At four months of age, 39% of infants were receiving mixed feeding, 30%
were predominantly breast fed, 8% were exclusively breastfed and the
remaining 23% had already been weaned. Of the mixed fed children, 83%
were in the process of weaning by this point, and by month 6 virtually
all children had ceased breastfeeding. 

Fluids other than breast milk were introduced into the diet very soon
after birth. Virtually all children not exclusively breastfed had
received water within a week of birth, and this was predominantly tap
water. 

A low feeding score at month 6 was significantly associated with a
lower height for age z score at months 12 and 18, and a lower weight for
age z score at months 9, 12 and 18, and this finding was not altered
when HIV-positive children were excluded from the analysis. Children
with a low feeding score at month 6 had a 50% higher risk of stunted
growth at any time point between months 7 and 18, leading the
investigators to conclude that "feeding practices during the critical
period around the weaning process seemed to be a predictor of the
child's future nutritional status. 

These findings need to be considered as a best possible outcome, the
authors conclude, because all women received breast milk substitutes
from the beginning of the weaning process until month 9, all received
intensive counselling and the women were required to recall all details
of infant feeding at least once a month in a 30 minute interview. 

These findings suggest a need for close attention to nutritional
support for mothers at the time of weaning, especially if mothers are
being encouraged to cease breastfeeding earlier than the local norm. 

Reference 

Becquet R et al. Complementary feeding adequacy in relation to
nutritional status among early weaned breastfed children who are born to
HIV-infected mothers: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote
D'Ivoire. Pediatrics 117 (4): 701-710, 2006.