RE: [pronut-hiv] AFASS (3)

["ALI MACLAINE" <alimaclaine@btinternet.com>]

Dear Married Guys, 

You should also factor in that powdered infant formula also is not a sterile product and has risks associated with it...
Powdered infant formula (PIF) has been associated with serious illness and death in infants due to infections with Enterobacter sakazakii. During production, PIF can become contaminated with harmful bacteria, such as
Enterobacter sakazakii and Salmonella enterica. This is because, using current manufacturing technology, it is not feasible to produce sterile PIF. During the preparation of PIF, inappropriate handling practices can exacerbate the problem.

Because of this there are guidelines that have been produced by WHO called: Safe preparation, storage and handling of powdered infant formula' 2006 (google it or go to WHO website and go from there). These guidelines set out the need to use boiled water at not less than 70 degrees C to make EACH feed and so on that have practical implications. Many tins of formula still do not incorporate these guidelines on their instructions on making up formula but people should be aware. 

There are not any easy answers with any of this unfortunately but good luck! 
Best wishes, 
Ali Maclaine.

--- Okanda, John wrote:



To the Married guys,

Sorry for the delay in getting back to you after your responded to my questions, I hope you haven't delivered birth yet! I want to thank those who have contributed to this chat like Lina, Thuts and others for their professional advice.

Lina has put it so well that you have two options; exclusive BF or exclusive FF. The final choice will be yours, but it has to be informed choice. I want to add to what Lina has professionally put forth. 

1.  If you choose to Formula feed: 

a.  There is no risk of transmitting HIV through exclusive formula feeding

b.The formula has to be prepared and fed correctly as Line did explain, if this doesn`t happen the baby will be more likely to get sick from diarrhea, chest infections and malnutrition. Thuts raised the issue of the baby`s caregiver who must be thoroughly trained on how to prepare and feed the baby correctly

c.From your response to my questions, I think you can afford and sustain formula feeds given your income and experience with feeding the previous baby

d.Formulas may not provide all the nutrients a baby may need, so supplementation may be necessary. Seek for nutritional advice on this 

2.If you choose to Breastfeed:

a.It has to be exclusively done, no water or any other drinks/foods. Only prescribed drugs from medics is allowed 

b.baby will be exposed to HIV in the breast milk and has chances of becoming infected with the virus

c.Breastfeeding has to be done exclusively and with ARVs for PMTCT, preferably HAART, to the mother (and the baby depending on the regimen) to reduce the risk of transmitting the virus to the baby. With your good CD4 count(550) if you are put on HAART, the risk will be lower


3.WITH YOUR GOOD CD4 CELL COUNT (550), INCOME AND EXPERIENCE WITH PREVIOUS FF; you can opt for either FF or BF but, the option that has the lowest risk of HIV transmission is formula feeding. 

4.WHO recommends exclusive formula feeding if it is acceptable, feasible, affordable, sustainable and safe

5.If the infant is HIV infected, it is strongly recommended that the infant be breastfed



Why Did I ask you for CD4 cell count and viral load?

*Â Â Â ÂÂÂSeveral clinical studies have associated low cd4 counts and or high maternal viral load with increased risk of vertical transmission and or mortality and morbidity;

o    A study by Louise Kuhn and others in 2006, Lusaka Zambia. Showed that infants born to HIV-Infected mothers with advanced disease (CD4<350 cells/uL) who escaped perinatal or early breastfeeding related HIV infection were nonetheless at high risk of mortality and morbidity in the first few months of life 

o    In Uganda, a study by Nakabiito and others in 2002. Showed that children whose mothers had a low CD4 cell count around the time of delivery had higher risk of infection

o    Leroy et. al. 2003, West Africa. Showed that maternal cd4 <500/mm in plasma close to the time of delivery was associated with increased risk of late postnatal transmission, 3times that of women with CD4 â500/mmÂ

o    In 2003, Read and others, in a meta-analysis of data from 9 interventional trials showed increased risk of postnatal infection in low cd4 counts; transmission increased 8times at CD4 <200/mm and 3.5 times at CD4 between 200 and 500/mmÂ, compared to reference group of CD4 >500/mm 

o    Closer home, Prof Ruth Nduati and others in 95. Found and associating between low CD4 in plasma with detection of HIV-DNA in breast milk.

*Â Â Â ÂÂÂFrom these studies, we can say that with CD4 count above 500, you have less chances of transmitting the virus to your infant perinatally



For your nutritional status/advice, seek nutritionists/dieticians one on one advice, though generally the WHO recommends increased energy intake over the levels recommended for healthy non-HIV infected persons, i.e. by about 10% in asymptomatic stage and between 20-30% in symptomatic disease and opportunistic infection to maintain body weight.



Regards,

John Okanda

Nutritionist 

Kisumu-Kenya 

 



-----Thuts wrote: 


Thanks Lina



That is a wonderful summarized way for the married guys. i do agree with all what you said but also to strenghten that when it comes to AFASS since this is a working couple it is critical to note that they will leave the child with another person. Is that person knowledgeble about the AFASS issues and is she going to be consistent in the preparation of the milk. Does she not need any additional support on continous basis and if so what kind of support. Does the couple have trust and faith that this person will implement according to the teachings. At the end of the day AFASS remains a challenge to be met when you have opted for a formula



Well done Lina



-------- Lina Njoroge wrote:



Hi Married guys.



Thank you for your inquiries and you are in the right forum.

I have been following your emails and I do applaud you for looking for professional Nutrition advise.I agree with John and as Nutritionist we give you the facts and you make the informed choice. So,in regards to the choice of feeding your second baby, understand the available options and make an informed choice.



In terms of Infant feeding choice it is either Exclusive breastfeeding for the first six months or Exclusive replacement feeding for the first six months. of worth noting is the transitioning after six months which will highly depend on your choice.but that can be discussed when you get there.



If you choose exclusive breastfeeding,then its important to really get in depth information and even demonstration on how to do it correctly in terms of attachment,positioning of the baby while breast feeding.Also checking for oral thrush in the infants mouth helps to make it safe.There is more information on this and even pictures to show you but it would benefit you to have a one -on -one with a Nutritionist to discuss further.Its important to do growth monitoring of the baby and also ensure good nutritional status of the mother especially during breastfeeding (and of course the father) as there is need for increased nutrient intake for the mother during the lactation period.More in depth infor on this available.



To choose Replacement feeding your choice should be based on a simple criteria referred to as AFASS citeria which simply stands for ;

A: Affordable That you and your family can be able to pay for the cost of the replacement feeds(only commercial infant formula recommended) plus other hidden costs of fuel,clean water,without compromising the families health and nutrition spending.(in your case you can from the emails i have read).You require 40 to 44 tins of Infant formula for the six months

F: Feasible You as the mother or any other family member have adequate time ,Knowledge and skills and other resources to prepare feeds and to feed your baby as well as have support to cope with family,community and social pressures( I guess all those questions that your husband deals with)

A: Acceptable As a mother or as parents,as long as you do not percieve any signifacant barriers to choosing a feeding option for cultural or social reasons or for fear of stigma or discrimination. Your choice of feeding your child should not be as a result of any pressure or culture.

S: Sustainable As long as you have access to a continous supply of all ingredients and products needed to implement the feeding option safely for as long as the baby needs it S: Safe That replacement feeds are correctly and hygienically stored, prepared and fed in nutritionally adequate quantities (basic hygiene practices,clean hands,clean utensils etc) of worth noting,safety is not in hygiene only but also the reconsitution of the feed to ensure that it is not over or under diluted.Number of feeds, frequency and duration are all important for eadequate growth and developement of the child.



So if one meets these conditions ,then they can go ahead. But you still need (whichever Infant feeding choice you make,to have indepth discussion with a qualified Nutritionist/Dietician to explore your options.)



Now in terms of Nutrition mangement, it is critical to see a nutritionist who will be able to do a proper clinical Nutrition assessment(Medical Nutrition Therapy for HIV which includes Nutrition assessment,counsellingand therapy interventions) as there is scientific evidence of relationship between HIV and Nutrition status and the immune system.



The Goal for Medical Nutrition Therapy is



  * Optimize Nutrition status immunity and overall wellbeing

  * Prevent the developement of specific Nutrient deficiencies

  * prevent loss of weight and Lean Body mass

  * To reduce risk of onsent or complications of cormobiditeis(ie diabetes, cardiovascular diseases, liver or Kidney diseases.)

  * to Maximize the effectiveness of medical and pharmacological treatments

  * Minimize health care cost.Basically a comprehensive Nutrition assessment is important for each of you so as to tailor a personalized diet plan.Its important to also know what regimen of ARV drugs you are on as this will also help determine the diet plan (Although most ARVs do not have alot of restrictions in terms of diet, there are certain Nutrients that may hinder or enhance drug absorption or vice versa.Also certain drug regimens may have adverse effects if combined with Alcohol and can cause other complications like pancreatitis and or liver toxicity.Taking plenty of water is also important. 



A comprehensive Nutrition assessment will include A,B,C,D, E ;

Anthropometric measurements -taking the weight, height and BMI,Waist circumference,body fat percentage( as there may be Physical body changes eg fat redistribution): 

Biochemical assessment of eg Blood sugar,cholesterol or lipid profile(as there may be metabolic changes),Haemoglobin levels to check for anaemia( there are some drugs that will induce anaemia),Albumin levels,liver function tests, Kidney function test such as Urea and creatinine levels. 

Clinical signs and symptoms (eg rashes,mouth ulcers,hair,palour,skin changes, etc)

Dietary assessment which will determine whether you are getting adequate nutreints based on your diet History, eating habits etc.Any clinical signs or symptoms.It is also important to know whetehr one is taking any other types of drugs apart from ARVS or other herbal remedies or supplements(As there may be drug-drug or drug-nutrient interraction and certain supplements or herbal remedies are contraindicated with certain ARVs. And Most importantly prompt/early nutrition intervention wil reduce the progression of HIV and make the immune stronger and reduce the risk incidences of opprtunistic infections.Evaluation or follow up is important to monitor especialy weight changes or any other nutrition related complications such as lack of appetite,vomitting, diahrroea, change in taste ,etc and how to cope/manage these symptoms.



But I thought its important for you to know this since you took this step of trying to get the right information on Nutrition. So nutrition care and support is individualized,very specific and specialized Care and support.And is available right here in Kenya and need not be expensive.Its just a matter of using the locally available foods to help you come up with an adequate and Nutritious diet.But it has to start form the Nutrition assessment.

So, I hope I have given you a brief synopsis of what Nutrition care and support is without overwhelming you with too much information for now.



Lina Njoroge

Clinical nutritionist