[pronut-hiv] What will replace breast milk at 6 months?

["Ted Greiner" <tedgreiner@yahoo.com>]

Six month old infants have very high nutrient needs compared to the size of their stomachs. International experience in feeding them when they do not have access to breast milk is limited to high income settings where infant formula and/or commercial fully fortified infant foods such as cereals are the foods of choice. When they form the foundation of the diet, then small amounts of other natural foods such as fruits, vegetables, legumes and animal foods can gradually be added with benefit.
   
  There is no documented body of experience in how to feed non-breastfed infants in a low-income setting. The principles are outlined in a WHO publication you can download from http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/ISBN_92_4_159343_1.pdf. The difficulty in implementing these principles in real life is illustrated by the fact that they recommend .5-1 liter of water a day for the infant to lower the renal solute load without telling us how to avoid all this water from reducing the child's appetite at meal times. 
   
  You can compose and cost daily diets for children in three age groups (one of which is 6-8) using a linear programming tool available for free download at http://www.nutrisurvey.de/lp/lp.htm. There are directions on the site you have to follow carefully to get it to work. It does not include all the foods you may have available in your setting; choose the most similar ones you can find. Pay attention to dry versus cooked values for grains and legumes, since they weigh 2-3 times as much when cooked. You can put in local prices per 100/g. You need to limit how much it uses of each food. Otherwise you will come up with diets requiring that the infant is fed amounts of foods that are unrealistic. How much the infant can consume in a day is limited by its relatively small stomach size and how much time and effort the mother or other family member can afford to give amidst their other duties each day. It will optimize the diet, based on the foods and maximum amounts you input
 linked to the RDA for the age range you have chosen so that the full energy needs are met and as much as possible of other nutrients. You can view a chart which nicely shows exactly how much of each nutrient RDA you are covering with that daily diet. 
   
  The diet is expressed in grams and you are likely to need many different nutritious foods if you do not put in formula or commercial baby food. I believe we are dreaming to assume any low-income mother can provide such a diet every day. 
   
  Hygiene is another major concern. At six months a non-breastfed infant is similar to an AIDS patient in that it is relatively immune-incompetent. Nature "expects" that breastfeeding will provide the immune protection the infant needs to survive. Again, there is very little international experience on how to achieve the very high levels of hygiene required to keep a non-breastfed 6 month old alive in a low-income setting. 
   
  All of the above is easier for a 12 month old infant and the levels of risk of death documented for not being breast fed at this age are much lower. 
   
  The expected level of HIV transmission to previously exclusively breast-fed infants who continue to be breastfed from 6-12 months is about an additional 3% based on the rates experienced by previously exclusively breastfed infants in the ZVITAMBO study. The increased risk of death from not being breast fed at the age of 6-12 months is only about 1.6 times as high as the baseline mortality rate at that age based on the WHO data published in Lancet in 2000 based on data from Brazil, the Philippines, and Pakistan. However, in the 1/3 of that sample of mothers that was most poorly educated, the risk rose to 5.1. 
   
  In Rwanda, for example, the risk of dying between 6-12 months for breastfed infants was 3.5% according to the 2000 DHS. (But you cannot obtain this from DHS reports. It requires special analysis.) If one takes this times 5.1 (given the low educational level of Rwandan women), it implies that about 18% of non-breastfed infants will die between 6-12 months of age. This must be compared to the 3.5% that otherwise would die + about 3% who would be HIV-infected through continued breastfeeding. The net LOSS to HIV-free surival rates would thus be over 10%. Stopping all babies from breastfeeding at 6 months in a setting like Rwanda is thus a very bad idea. 
   
  In addition, if health workers pressure mothers to do something they feel they cannot do, then the mothers feel ashamed and guilty and stop telling the health workers what they actually are doing. In Rwanda, over half the babies are breastfed for over 3 years, resulting in a very long exposure to HIV via breast milk if the mother is infected. If the health worker instead maintains a good (non-scolding) relationship with the mother, it should be possible to safely stop breastfeeding at 1-2 years even for the very poor mothers, reducing postnatal HIV transmission rates by about half with very little danger of increased mortality. This is equivalent to the widely hailed impact on perinatal transmission rates of single-dose NVP, and thus, while perhaps not what we might dream of achieving under ideal conditions, is still a worthwhile goal to pursue.
   
  Bottom line: pushing low-income HIV-positive mothers to stop breastfeeding at 6 months may kill a net excess of 10% or more of the babies, while for others driving the behavior "underground" and cutting off communication between health worker and mother so that breastfeeding continues for an unnecessarily long period of time.
   
  Ted Greiner
   
-------"Rachel Stern" wrote:


The bigger question, then, is what does replace 
breast milk at 6 months? 
Practically speaking, I mean.