Re: [pronut-hiv] What will replace breast milk at 6 months? (3)

["Rachel Stern" <sternworks@verizon.net>]

Thank you, Ted, for this detailed response.

I personally feel that formula should be made available to new mothers who 
are willing to use it for their babies from birth, and who can prepare it in a reasonably clean way. If medications can be subsidized, couldn't/shouldn't formula also be subsidized? All the rates of mortality and for HIV transmission that you cite, remain unacceptably high.

But for those who do brestfeed, and who continue past 6 months, do you know the specific route of transmission? Is it through a permeable intestinal tract? lesions in the babies mouth or lips? cutting teeth? Does the route change as the newborn baby infant gets older? Maybe there could be a way to reduce transmission in younger and older infants - I mean, something beyond the "exclusivity" thing which I don't find very impressive.

If the mother is taking antiretrovirals and other meds, do these pass into 
breastmilk, and is this considered good (by limiting transmission) or bad 
(toxicity issues)?

Just curious about these questions.  Thanks.


-----"Ted Greiner" wrote:


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.