Re: [pronut-hiv] Balancing infant feeding risks for mother and child (2)

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

Ted - I'd have to read these reports in order to respond. I'm wondering, for example about the Pakistani report: Were these mothers HIV+? Did these 
mothers reconstitute powder, reconstitute concentrated liquid, or use 
ready-to-feed formula?  Did these mothers have to purchase their own 
formula, thereby putting the infants at risk of inadequate intake?  I'm just not sure that the experiences you cite would be relevant to the safety of a formula-feeding program, carefeully targeted to prevent HIV transmission.

I don't think there's any doubt that formula feeding was a diseaster, as it was probably practiced in Pakistan, Brazil, the Phillippines, and many other countries during the period when formula gained a foothold. The superiority and other benefits of breastfeeding and of breastmilk, including its contraceptive effects, are well known. But so are the benefits of HIV prevention, and perhaps at least in some regions an innovative and carefully crafted formula program could save infants from a lifelong HIV infection.

The poorest, most poorly educated women may have a surprising capacity to 
take this kind of prevention measure, if provided with the right resources.

As for anemia and menstruation, nutrional depletion as well as breastfeeding (and in this case, the two are probably interrelated) cause a delay in return of menstruation and fertility. Unintended pregnancies often occur when fertility returns before menstruation returns. I agree with you on the importance of family planning services. I'll try to find the WHO Bulletin articles you mention, although intuitively, their conclusions don't sound reasonable.

Again, thanks for your thoughtful response.

Rachel

----- "Ted Greiner"wrote:

Dear Rachel,

  Yes, per person over the long run formula would be cheaper than HAART, 
though in one program I know of that provides both, the budget for each is 
about the same because so many fewer patients receive HAART.

  The proportion of infants who die from formula feeding can easily be far 
above the proportion that becomes infected from breastfeeding. The worst 
documented case is infants under 1 month in Pakistan where 21 times as many 
died if not breastfed.

  In Pakistan, Brazil and the Philippines, 5 times as many died if not 
breastfed at 6 months of age among mothers in the lowest education tercile 
compared to almost no excess death among those in the highest education 
tercile.

  For HIV+ mothers, AFASS assessment for whether to breastfeed, and again, 
when to stop for those who choose to breastfeed, should be based on the 
individual because, as you say, there can be exceptions.

  But for a donor interested in improving public health and utilizing scarce 
resources in a cost-effective way, purchasing infant formula will come very 
far down on any priority list of interventions. For those seeking to improve 
equity (which is a goal for most donors), giving formula alone, with no 
benefit to the women who choose breastfeeding, will actually increase 
inequity.

  While it is reasonable to assume what you say about breastfeeding being 
tiring to HIV+ women, nature has worked out clever ways to ensure that 
breastfeeding is a "win-win" proposition for women. More intensive 
breastfeeding on average delays the return of menstruation, and this is 
particularly protective for those women who tend to lose more than the 
average amount of blood monthly in menstrual bleeding. And they are the ones 
most vulnerable to anemia. Anemia tends to be pretty exhausting as well. Not 
only will non-breastfeeding women be more subject to anemia, unless they 
quickly start to practice modern contraception, they are likely to get 
pregnant again quickly, and short birth spaces are by far the most 
exhausting and dangerous situation for women of reproductive age, let alone 
those with HIV. In my experience, few PMTCT sites offer adequate family 
plannning support and services to overcome this risk. There are now three 
studies finding no excess morbidity or
 mortality among HIV+ mothers who breastfeed, including one from Malawi in 
the latest issue of WHO Bulletin, full text articles from which are 
available free online.

  Ted Greiner
---Rachel Stern wrote:

Thanks Ted, for this point-by-point explanation.
This is very interesting
information. Just a couple of more thoughts in
response:  As for cost, this would be a limited
time of about a year versus HAART which at the
moment seems open-ended. Although the impact of
formula is so far unproven, if stix show that 6 or 8 or
15% or whatever babies acquire HIV during
breastfeeding, it stands pretty much to reason that
formula would prevent that amount of transmission.
However, maybe providing formula for those with an
AIDS dx, or some other cutoff (as you note),
makes more sense.  A woman with AIDS may find
breastfeeding adds to her exhaustion, and her milk
production may be compromised.

What about cutting teeth? what is recommended
during this extensive period?

I'm not sure I agree with you that less educated,
less wealthy women could
not provide formula safely. That would no doubt
vary from area to area.

I realize there are many obstacles including cost
and hygiene, and it
certainly goes against what we all understand -
that breastmilk and
breastfeeding are superior. But not always.

Thanks.  Rachel