Transcript HIV in breast milk

Postpartum AFASS assessments to
support appropriate timing of cessation of
breastfeeding
Ted Greiner, PhD
1st Regional
Conference on
Human Lactation,
Breastfeeding for
Healthier Generations
November 14 – 15,
2007
Dubai
The goal of infant feeding
counseling & support:
Achieve optimal rates
of HIV-free survival
 Reduce postnatal
HIV transmission
 Keep infants alive
and well
Breastfeeding Dilemma
•
Recommendations regarding breastfeeding for the HIVinfected woman must carefully consider the risk-benefit ratio
for that particular individual.
•
The risk-benefit ratio for replacement feeding can vary
substantially among different settings and in many cases may
be difficult to determine.
•
The risks of alternative feeding methods may include the
following:
− Increased morbidity/mortality.
− Impact of the cost on the health sector budget and on the
family (higher health care costs for all instead just the few
percent who transmit).
− Loss of lactational ammenorrhea.
− Stigmatization if breastfeeding is the norm.
Protective components
of breast milk
•
At birth, infant absorbs most
macromolecules directly
through its mucosa (absorptive
barrier in the digestive system)
– ingestion of breast milk
accelerates the maturation of
mucosa, part of the infant’s
immune system.
•
While the infant gut matures,
breast milk protects the infant
digestive system with
antibodies and other
bioactive elements from
pathogens.
Picture source: Newburg and Walker, 2006.
•
The breast milk suppresses gut inflammation, which protects the infant
mucosa from damage.
Source: Newburg DS, et al. Protection of the Neonate by the Innate Immune System of
Developing Gut and of Human Milk. Pediatric Research. 2007;61(1).
HIV and infant digestive tract
HIV in breast milk:
1. mouth cavity
• cell-free HIV versus
cell-associated HIV
The HIV virus is not likely to enter the infant’s body
through the mouth cavity, unless that cavity is
damaged (e.g., thrush, lesions).
• factors affecting viral
load:
• stage of mother’s
HIV progression
2. stomach
As the infant’s digestive function is immature,
especially before 6 months of age, components of
mother’s breast milk serve as protection against
disease. Most of the cell-free HIV is probably killed
before entering the lower digestive tract (i.e.
intestines). Mixed feeding is particularly
dangerous, as it does not offer similar protection
and allows for damage to the intestinal mucosa.
[primary infection and
later stages of HIV and
AIDS both cause high
viral load in breast milk]
• mastitis of the breast
3. small intestine
[causes higher viral
load in breast milk]
• abrupt weaning
[causes high viral load
in breast milk]
Diagram source: AMA, 1999.
Damage to lining of the intestine (mucosa) may
create entry points for HIV into the infant’s body.
Exclusive breastfeeding protects the mucosa
from damage.
More research is needed on physiology of HIV
transmission through mucosa.
Sources: Thea DM, et al. Post-weaning breast milk HIV-1 viral load, blood prolactin levels and breast milk volume.
AIDS. 2006; 20(11):1539-1547. John-Stewart G, et al. 2004. Breast-feeding and transmission of HIV-1. JAIDS. 2004
Feb 1; 35(2):196-202.
Timing the introduction of replacement feeding
Additional
Risk of
Death
Not Breastfed
Breastfed
0
optimum
Age
Source: Ross/LINKAGES,
2000
Risk of late postnatal HIV
transmission, ZVITAMBO*
• Partially breast-fed infants: 1%/mo
at 1.5-6 months, 0.8 at 6-18 mo
• Exclusive BF for 3 mo: 0.3%/mo for
age 1.5-6 months
• Complementary-fed infants (6-18
mo) formerly EBF: 0.5% / month
*Iliff
PJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1
transmission and increases HIV-free survival. AIDS. 2005 Apr 29;19(7):699-708.
Infant mortality risk from not breastfeeding
Pooled Odds Ratios
6
5.8
4.1
4
2.5
2
1.8
1.4
0-1 mo
2-3 mo
4-5 mo
6-8 mo
9-11 mo
0
Age in months
WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant
Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in
less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5.
When does RF from birth lead to greater HIV-free survival than BF
by HIV+ mothers: A risk analysis
Deaths Plus HIV Infections
Estimated # HIV infections + deaths at 24 months/1000 live births
500
450
400
350
300
250
200
150
100
50
0
BF 24
RF 24
EBF 6
0
50
100
150
Infant Mortality Rate
Piwoz & Ross, Journal of Nutrition, 2005
What is the infant mortality risk
from not breastfeeding?
12
Ghana
Pooled Odds Ratios
10
Lowest tercile of
mat. education
8
6
4
2
0
0-1 mo
2-3 mo
4-5 mo
6-8 mo
9-11 mo 12-24 mo
WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant
and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5.
Comparison of Overall Mortality Among HIV
Uninfected Babies in PEPI versus NVAZ (no
early weaning advice)
Source: MG
Fowler
What happens when breastfeeding
completely stops?
• Depends on child’s age and how fast the “sevrage”
takes place; <2 weeks is feasible, we do not know if it
is advisable
• Before 6 months increases risk
• Psychologically stressful to mother, child, and rest of
family
• In Uganda 25/47 stopping before 7 mo got mastitis
(increasing infectivity of breast milk, and risking HIV+
mother’s health)*
• Children become depressed and often anorexic;
19/47 in Uganda quickly got sick or lost a lot of
weight*
*Bakaki PM. In: Greiner et al, 2002.
Nutrient contents, foods for the
non-breastfed infant
• WHO’s Guiding Principles for Feeding Nonbreastfed Children 6-24 Months of Age:
http://www.who.int/child-adolescenthealth/New_Publications/NUTRITION/ISBN_92_
4_159343_1.pdf
• A linear programming tool that can help in
composing a diet is found at
http://www.nutrisurvey.de/lp/lp.htm.
• Heat treatment of expressed breast milk
deserves more attention as a partial solution;
breast milk can be added during cooking in
porridge etc
Typical & Inadequate
at 6-9 mo
9 Tporridge, 1 t sugar, 1 t oil
4 T sadza
2 T fish and
tomato soup
13 T plain pumpkin
322 kcalories (38% needs); 24% kcal as fat, 8 g protein (52% needs);
Deficient in all micronutrients except Magnesium and Folic Acid
(ZVITAMBO Study Group, Toronto, 2006)
*More milk and sugar
= closer to Adequate
480 ml cow milk or formula
1 banana
1 cup porridge
4t oil
2T sugar
851 kcalories (101% needs); 38% kcal as fat; 20 g protein (128% needs);
Adequate in Ca, Must supplement Fe/Zn and multivits.
Must add 220-520 ml water
(ZVITAMBO Study Group, Toronto, 2006)
2000 and 2006 WHO Recommendations
•When replacement
feeding is acceptable,
feasible, affordable,
sustainable and safe,
avoidance of all
breastfeeding by HIVinfected mothers is
recommended.
• Exclusive breastfeeding is
recommended for HIV-infected
women for the first 6 months of
life unless replacement feeding
is acceptable, feasible,
affordable, sustainable and safe
for them and their infants before
that time.
• Otherwise, exclusive
breastfeeding is
recommended during the
first months of life.
• When replacement feeding is
acceptable, feasible, affordable,
sustainable and safe, avoidance
of all breastfeeding by HIVinfected women is recommended
New 2006 WHO guidance
• Exclusive breastfeeding does carry lower risk of HIV
transmission than mixed feeding
• HIV-infected infants should continue to be breastfed
• Repeated assessments of feeding choice with mother
• Breastfeeding beyond 6 months may be best for some HIVexposed infants
• Counselling should focus on 2 main options (replacement
feeding and exclusive breastfeeding for 6 months), with other
local options discussed only if mother interested
• Home-modified animal milk no longer recommended for all of
first 6 months – only to be used as short-term measure
Ted Greiner, PhD
[email protected]
Thank you