PASTEURIZED BREASTMILK AS A REPLACEMENT FEED FOR THE BABIES OF HIV-INFECTED MOTHERS CURRENT INTERNATIONAL HIV AND INFANT FEEDING GUIDELINES suggest that when children born to women living with HIV can be ensured uninterrupted access to nutritionally adequate breast-milk substitutes that are safely prepared and fed to them, they are at less risk of illness and death if they are not breastfed. It is considered that milk in some form is essential, and replacement feeding options include commercial infant formula, and home prepared formula which can be made from animal milks, typically from cows, goats, buffaloes or sheep (UNAIDS 1998). However, the possibility that mothers could use their own treated breastmilk as a replacement for breastfeeding directly has received scant attention. A study conducted in 1993 (Orloff et al) for the Human Milk Banking Association of North America established that HIV in breastmilk could be inactivated by Holder pasteurization (heating to 62.5 degrees C for 30 minutes). Dr Caroline Chantry and colleagues published a paper in 2000 describing a small study conducted in Puerto Rico to examine virus in the expressed breastmilk of a small number of HIV+ mothers.  Although  HIV could be identified in the milk of 88% of the women, it could not be recovered from any of the samples after flash-boiling  (bringing breastmilk just to boiling point, so that bubbles appear around the edge of the pan). (Chantry 2000).  In 2000 and 2001, Dr Bridget Jeffery in Pretoria described and researched another method of home-pasteurization which could be employed using very simple implements available in the homes of ordinary women living in resource-poor settings.  (Jeffery et al 2000, and 2001)  The Zimbabwe Ministry of Health officially presents the use of expressed breastmilk as a primary option to be considered by HIV+ mothers  (Zimbabwe Ministry of Health 2000) PASTEURIZATION OF BREASTMILK AT HOME, using simple equipment, is not only safe, but possible.  Home-heated expressed breastmilk is the most logical feeding alternative for those women who wish to avoid any possibility of transmission of the virus to their babies by breastfeeding, yet wish to provide them with the most physiologically suitable milk for human infants.  The mother who provides her own milk for her baby has absolute control over her own milk supply and can assure her baby's food security for the whole time that she lactates. Heat-treated EBM is nutritionally superior to other replacement feeds, maintains some immunological protection, avoids the risk of allergy, and costs nothing.  In addition, the hormonal impact on a mother who continues to lactate is likely to result in less stress, increased enjoyment of her baby and longer lactational amenorhhea, which contributes to a longer interval before the birth of the next child. EXPRESSING BREASTMILK:  Guidelines for Mothers 1.  Start expressing colostrum within a few hours of baby's birth. 2.  Continue to express the breasts very thoroughly at least 7 times in 24 hours (every 3 hours in the day, with perhaps one longer interval at night) to provide enough milk for the baby and keep the breasts soft and comfortable. 3.  Express the breasts more often if they become overfull - it is vital to continued long-term breastmilk production that the breasts are drained often enough (especially from Day 4 - 9 postpartum) to avoid/resolve engorgement.  Also express more often (even every hour) if you are not producing enough milk for your baby. 4.   After Day 10, on-going breastmilk production is directly dependant on drainage of the breasts and the amount produced may fluctuate from day to day. Mothers may be able to express less often than 7 times in 24 hours once lactation is well established, but may need to express more often again if they experience a drop in milk supply. STORING BREASTMILK Expressed breastmilk should be stored in covered containers, eg a jam-jar.  Breastmilk may retain more nutrients if stored in brown glass, rather than clear glass. Feeding bottles and teats, if used, should be sterilized.  Containers for storing breastmilk, and cups and spoons for feeding should be washed and clean, but need not be sterilized. Breastmilk can be safely stored at the following temperatures, for the following lengths of time: Room temp cool day (< 25 degrees C           10 hours Room temp  hot day  (> 25 degrees C)           6 hours Refrigerator (4 degrees C)                              8 days Freezer (0 degrees C)                                    6 months Breastmilk in a sucked bottle or from a sucked cup need not be discarded.  Leftover breastmilk can be refrigerated for 48 hours, re-warmed, and fed to baby - don't do this more than once. PASTEURIZING BREASTMILK Method 1.  Flash-boiling. Place milk in clean covered jar in a pan of water.  Place pan on stove and heat until bubbles appear around the edge of the milk.  Cool milk and feed to baby. Method 2.  Pretoria pasteurization Place 50ml - 150 ml into a clean covered glass jar.  Boil 450 ml water in a small aluminium pot, and remove from heat-source. Place milk jar upright in the pan of boiled water, cover the pan and leave for 15 - 20 minutes.  Cool milk and feed to baby. NOTE ABOUT PASTEURIZATION OF COLOSTRUM: (as yet, unresearched) Small quantities will be difficult to heat.  Would suggest adding drops of expressed colostrum to small quantity (10  20 ml) of still-hot, previously boiled water.  Feed cooled colostrum-and-water by teaspoon in tiny quantities (drop by drop) until breastmilk quantity increases sufficiently (36 - 48 hours after birth) to be able to use above methods of pasteurization. FEEDING EXPRESSED BREASTMILK The baby will require the following quantities of breastmilk in order to grow well and thrive (Adequate weight gain is considered to be a gain of 30g/day after the third day of life and up to 3 months, and 20g/day from 3 - 6 months):         Day 1 -     approx 30 ml colostrum**         Day 2 -       60ml per kilogram per day         Day 3 -       90ml     "         Day 4 -      120 ml  "         Day 5-10 - 150 ml  "         From Day 10 - 180ml/kg/day         ** 28g = 1 oz The baby can be fed the pasteurized, cooled breastmilk by cup, spoon or bottle.  Note, however, that bottle-feeding can be hazardous in resource-poor environments since bottles and teats need to be thoroughly sterilized before use. REFERENCES: Brusseau R  1998, Analysis of refrigerated human milk following infant feeding (unpublished study). Chantry CJ, Morrison P, Panchula J, Rivera C, Hillyer G, Zorilla C, Diaz C.  Effects of lipolysis or heat treatment on HIV-1 provirus in breast milk. J Acquir Immune Defic Syndr 2000;24(4):325-9 Jeffery BS, Mercer KG, Pretoria pasteurisation: a potential method for the reduction of postnatal mother to child transmission of the human immunodeficiency virus, J Trop Pediatr 2000;46(4):219-23 Jeffery BS, Webber L, Mokhondo KR and Erasmus D, Determination of the Effectiveness of Inactivation of Human Immunodeficiency Virus by Pretoria Pasteurization,  J Trop Pediatr 2001; 47(6):345-349 Morrison P, Morrison P. HIV and infant feeding: to breastfeed or not to breastfeed: the dilemma of competing risks,          Part 1. Breastfeeding Review 1999;7(2):5-13          Part 2. Breastfeeding Review 1999;7(3):11-19. Orloff SL, Wallingford JC, McDougal JS 1993,  Inactivation of human immunodeficiency virus type 1 in human milk: effects of intrinsic factors in human milk and of pasteurization. J Hum Lact 9(1):13-17. UNAIDS/UNICEF/WHO 1998, HIV and infant feeding:  A guide for health care managers and supervisors, WHO/FRH/CHD/98.2 Zimbabwe Ministry of Health and Child Welfare, Infant Feeding and HIV/AIDS; guidelines for health workers in Zimbabwe; June 12, 2000 Prepared in January 2003 by: Pamela Morrison International Board Certified Lactation Consultant 10 Camberwell Close Borrowdale Harare Zimbabwe email:pamela@ecoweb.co.zw