Re: [pronut-hiv] The requirements and problems with providing free formula in Africa (2)

["Kristof & Stacia Nordin" <nordin@eomw.net>]

What about using ready to feed infant formulas?  Would the only barriers be cost and potentially contaminating the formula by saving an open bottle 
improperly or using dirty feeding cup/bottle.

Has someone approached the big formula companies at part of their social 
responsibility to produce a one serving ready-to-feed formula tailored to 
the needs of infants in Africa and other similar settings?  It seems like 
this issue is on the heart strings of many people and that there would be 
some organization out there to champion this.

Of course, I'd still like to pursue my other idea of producing local 
formulas with local ingredients with local people, but I'm all out of ideas 
to follow;  seems like I've hit all dead ends at this point.

Stacia Nordin, RD
Malawi, Africa

-----  "Ted Greiner" wrote:


Dear Rachel,

  If intuition had proven to be good enough, we wouldn't need evidence-based 
medicine.

  Formula feeding CAN work in Africa, but it requires provision of free 
formula, clean water, and fuel for a long time (Family Health International 
gives it for 18 months in two districts in Rwanda). FHI also asks the 
mothers to come for the formula every 2 weeks, when a qualified health 
worker checks the child, someone with access to the drugs needed to save 
those who come down with the numerous diseases artificially fed infants 
always suffer from, but need not die from if and when good health care is 
available close to home. (Like AIDS patients, non-breastfed infants are 
immune-incompetent.) So, while definitely possible, the cost of getting free 
formlua to work and NOT having it actually decrease HIV-free survival rates 
is high indeed.

  However, when scaled up, even in the better resourced countries of 
southern Africa, free formula is not working very well. In South Africa, the 
recently completed (still unpublished) Good Start study found that nearly 
all women on free formula had periods of time when the formula ran out and 
they were not yet eligible to get more or there was none to be had when they 
travelled to the health center for their monthly ration because it had run 
out there too. Bergstrom, in a sub-study done in Durban, found that even 
among mothers with some high school education and a fridge at home, 2/3 had 
fecal bacteria in the bottles they were giving to their babies. Her thesis 
is freely available at http://www.hst.org.za/publications/564.

  In Botswana, the other African country providing free formula to HIV+ 
mothers, a recent rise in the water table contaminated the usually reliable 
water supplies and over 10,000 infants, mainly those receiving free formula 
under their national PMTCT program, were hospitalized with diarrhea. About 
500 died. Like you say, it's nice to avoid HIV transmission, but it's very 
dififcult in most African environments to avoid paying too high a price for 
doing so by avoiding breastfeeding.

  Meanwhile, as HIV testing, CD4 testing and HAART availability expand, much 
if not most postnatal transmission will disappear, as it is mainly HIV+ 
women with a low CD4 who transmit though breast milk.

  Cheers,
  Ted

--- Rachel Stern wrote:

  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