Re: [pronut-hiv] Care of HIV positive breatfeeding women (3)

["Pamela Fergusson" <p.fergusson@chester.ac.uk>]

Hi Stella,

Breastfeeding women have higher nutrient requirements. Lactating 
women are recommended to get about an extra 500 kcal per day - and 
increased protein as well. 

HIV positive women, even if they don't have an opportunistic infection, 
need about 10% more calories than HIV negative women. 

Those two factors put together mean that Jane is likely just not getting 
enough calories - macro and micro nutrients to meet her requirements. I 
might guess that Jane is getting less than half of what her body requires 
at the moment. 

Unfortunately Jane is not alone. This is a situation faced by so many 
HIV positive, breastfeeding moms. 

I think that it is wonderful that you are supporting Jane to continue with 
her exclusive breastfeeding. You might want to discuss with Jane what 
other options she might have to increase her food intake - either from 
resources within her home and community - or if there is any food based 
support programmes available to her (community kitchens, community 
gardens, food baskets, supplementary feeding etc.)

Encourage Jane to eat nutrient dense foods like: nuts, beans, pulses, 
eggs, meat, oil, goat's milk or cow's milk and brightly coloured fruit and 
vegetables - esp dark green or bright orange fruits and veg. (like mango, 
pumpkin, pumpkin leaves, sweet potato etc... or whatever is available 
locally)

Best regards, 
Pamela. 

Pamela Fergusson RD
Lecturer Nutrition and Dietetics
University of Chester 
Parkgate Road 
Chester CH1 4BJ 
UK

Quoting Mundi Stella <smundi2005@yahoo.com>:

>    
>   Dear colleagues,
>   I wrote to this forum a couple of weeks ago looking for guidance on 
abrupt
> cessation of breastfeeding. I got some help from Ted. The HIV positive 
young
> women (Jane)came to the clinic two weeks ago with her baby for the 
follow up
> visit. The baby was doing very well, but Jane looked very pale and had 
lost
> some weight. Jane did not have any opportunistic infection and was 
still
> taking iron/folate tablets. The problem is that Jane gets only one meal 
a
> day. I am a little bit worried about Jane. 
>   Have you noticed some weight loss in HIV+ women who are 
breastfeeding? 
> What do you do in such situation? What are the recommendations 
regarding the
> care of HIV positive breatfeeding  women?
>   
>    Thank you 
>    
>   Stella
> 
> 
>   ------------------------------------------------
> Ted Greiner <tedgreiner@yahoo.com> wrote:    Sure. This means it is 
not worth
> the time of the health worker to get into complex prenatal counselling 
(as
> per UN guidelines) unless she can tell that a given mother is well off. I
> suspect that's what's happening in most African countries. The 
problem then
> becomes that health workers do not know enough about how to 
support exclusive
> breastfeeding and mothers need help in the community--otherwise 
mothers in
> law in particular oppose it.
>    
>   The sad thing is that counselling definitely is needed to decide when 
to
> stop breastfeeding and WHO gives almost no practical advice on how 
to do
> that. We hope to test an algorithm I've designed for this purpose in a 
couple
> African countries in the near future.
>    
>   Cheers,
> Ted
> 
> Mundi Stella <smundi2005@yahoo.com> wrote:
>     Thanks Ted, this is very useful. 
>   I agree partially with the recommendation to counsel HIV positive 
women so
> that they can choose the most appropriate feeding option for their 
infant.
> From my experience, only wealthy HIV positive women can make that 
choice.
> Most HIV positive women attending the antenatal clinic choose to 
breastfeed
> their infant because they cannot afford breastmilk substitute. 
>    
>   Stella
>    
>     Ted Greiner <tedgreiner@yahoo.com> wrote:
> 
>     Dear Stella,
>    
>   Thank you for this question, which raises important issues.
>    
>   First, if the family cannot afford milk, I do not think it is appropriate
> to stop breastfeeding before about a year of age. With no milk or other
> animal foods (such as liver and eggs) it is impossible to provide a
> nutritionally acceptable diet that will allow an infant to survive and be
> healthy.
>    
>   Second, the rate of transmission of HIV during exclusive 
breastfeeding is
> so low that the most recent published simulation study (Piwoz and 
Ross)
> suggested that it makes no sense to do replacement feeding in a 
setting where
> the infant mortality rate is likely to be higher than 25/1000 live births.
> (You do not say what country you are writing from but I do not believe 
that
> anywhere expect possibly wealthier urban areas of South Africa has 
such a low
> IMR in Africa.) Thus stopping exclusive breastfeeding before six 
months is
> hardly advisable in such a case.
>    
>   Third, in 1998 the Coutsoudis study showing that exclusive 
breastfeeding
> resulted in a lower HIV transmission rate (later confirmed by data from 
the
> ZVITAMBO study in Harare and the DITRAME study in Abidjan) resulted 
in an
> inappropriate assumption that mixed feeding after six months of 
exclusive
> breastfeeding is as dangerous as it was shown to be by those three 
studies in
> the first three months of life. While no research has been done on this, 
I
> greatly doubt this is true, if only because the infant gut is completely
> different in a newborn compared to a healthy six month old. Honey or
> nitrate-rich water can kill newborns but not older babies; newborns' 
guts are
> so immature that they can absorb entire proteins instead of breaking 
them
> into amino acids as six month olds do; until about 8-9 months of life, 
some
> of the lighter proteins in cow milk appear to cause occult gut bleeding
> unless the milk is boiled for some time before being fed to the baby--
not
> just pasteurized. 
>    
>   Interestingly, infants who were exclusively breastfed in the first three
> months of life in the ZVITAMBO data transmitted HIV at a lower rate 
during
> the 6-18 month period than those who were mixed fed during the first 
three
> months (5.6% versus 9.6%), though I was informed that this was not a
> statistically signficant difference.
>    
>   In most of Africa, the risk of death from not breastfeeding is likely to be
> quite high. Bahl et al, using combined data from Ghana, India and 
Peru,
> recently found the death rate to be 10.5% higher in the period 6 weeks 
to 6
> months. This is 2-3 times as high as the rate based on old studies in 
one
> city each in the Philippines, Brazil and Pakistan used in the Piwoz and 
Ross
> simulation. The proportion likely to get HIV during breastfeeding during 
the
> period 1.5-6 mo varies from about 1.5% to 5%, depending on whether 
the
> breastfeeding is exclusive. Thus stopping breastfeeding would make 
sense only
> if the infant mortality for that 1.5-6 mo period was under 5/1000, which 
one
> sees only in industrialized countries. 
>    
>   Another factor to consider is Jane's health and immune status. If she 
has a
> high CD4 count (or if you do not know it, if she has not lost much 
weight in
> the past year or so), then her chances of transmitting HIV are less than 
if
> her CD4 count is below say 350 (or if her BMI<19 or her weight loss 
>5%
> recently), when the risk of transmission goes up.
>    
>   Regards,
>    
>   Ted Greiner, PhD
>   Senior Nutrition
>   Director, Ultra Rice Program
>   PATH
>   1800 K St. NW, Suite 800
>   Washington DC 20006 USA
>   +1 202 822-0033
>   Fax +1 202 457-1466
>      
>   Message: 2
> Date: Mon, 17 Apr 2006 07:00:44 -0700 (PDT)
> From: "Mundi Stella" <smundi2005@yahoo.com>
> Subject: [pronut-hiv] Help with transition to 
> replacement feeding
> To: pronut-hiv@healthnet.org
> Message-ID: 
> <20060417140044.54298.qmail@web38410.mail.mud.yahoo.com>
> Content-Type: text/plain; charset="iso-8859-1"
> 
> Dear colleagues,
>    
>   I am a midwife in antenatal service in the 
> district hospital and will 
> be meeting with a 21 year old young woman (Jane) 
> who delivered three 
> months ago in the maternity. Jane is HIV positive 
> and decided to 
> exclusively breastfeed her baby. 
>   I will be meeting with Jane in two weeks to 
> counsel her on abrupt 
> cessation of breastfeeding and how to transition 
> to replacement feeding. 
> Jane lives with her parents and does not have any 
> income. Jane?s parents 
> do not know about her HIV status. They cannot 
> afford to buy milk. The 
> only replacement feeding is available is ?family 
> foods?. I am very 
> challenged by Jane?s situation. Jane?s parents 
> may become very suspicious if Jane stops 
> breastfeeding their grand child. Family foods may not be 
> well tolerated by Jane?s baby. 
>    
>   Any idea or suggestion on how to go about this 
> situation will be much 
> appreciated
>    
>   Thanks 
>    
>   Stella 
> 
>> 


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