Zachary Ochieng
14 January 2008
Nairobi — EXCLUSIVE BREASTFEEDING (EBF) - giving an infant only breast milk without any additional food or drink, not even water - reduces the chance of post-natal mother-to-child HIV infection by almost half.
On the other hand, not using EBF more than doubles the risk of early post-natal HIV transmission. Consequently, programmes to support EBF should be expanded universally in low resource settings.
These findings are contained in a report of a study conducted in southern Africa and published in PLoS Medicine, an open access peer reviewed medical journal published by the American Public Library of Sciences.
EBF is an affordable, feasible, acceptable, safe and sustainable practice that reduces HIV transmission and provides HIV-infected women with a means to protect their children's lives. According to the study, empirical data showing the clear benefits of EBF for HIV prevention are needed to encourage implementation of lactation support programmes for HIV-infected women in low-resource settings among whom replacement feeding is unsafe.
International guidelines recommend exclusive breastfeeding for the first six months based on scientific evidence of the benefits for infant survival, growth and development.
Breastmilk provides all the energy and nutrients that an infant needs during the first six months. Exclusive breastfeeding reduces infant deaths caused by common childhood illnesses such as diarrhoea and pneumonia, hastens recovery during illness, and helps space births.
Moses Sinkala of the Lusaka Health Management Team, Chipepo Kankasa and Prisca Kasonde of the University Teaching Hospital, Lusaka, Nancy Scott of the Boston University School of Public Health, among others conducted the study titled: High Uptake of Exclusive Breastfeeding and Reduced Early post-natal HIV Transmission.
THE RESEARCHERS CONDUcted a prospective, observational study in Lusaka, Zambia, to test the hypothesis that EBF is associated with a lower risk of post-natal HIV transmission than non-EBF.
As part of a randomised trial of early weaning, 958 HIV-infected women and their infants were recruited and all were encouraged to breastfeed exclusively four months. Single-dose nevirapine was provided to prevent transmission.
Regular samples were collected from infants of up to 24 months. Detailed measurements of actual feeding behaviours were collected to examine, in an observational analysis, associations between feeding practices and post-natal HIV transmission.
"Uptake of EBF was high with 84 per cent of women reporting EBF cumulatively to four months.
Post-natal HIV transmission before four months was significantly lower (0.004 per cent) among EBF than non-EBF infants (0.102 95 per cent). There were no significant differences in the severity of disease between EBF and non-EBF mothers," the study says.
Promotion of EBF has been a cornerstone of public health measures to promote child survival for several decades. EBF is associated with lower risks of diarrhoea and pneumonia-related infant morbidity and mortality than breastfeeding with addition of other fluids and solids in both developed and developing world settings.
EBF facilitates normal physiological regulation of milk production, which depends on regular infant suckling, allowing for a healthy balance between the infant's needs and the amount of milk produced. This regulation helps prevent milk stasis that underlies the development of mastitis and other breast problems, thereby being the healthiest practice for both mothers and infants.
The study says that despite the well-established benefits of EBF in the absence of HIV, initial findings from Durban, South Africa, that the risk of post-natal HIV transmission was lower with EBF than with non-EBF were met with some scepticism.
Nevertheless, the finding was soon confirmed by a second large study conducted in Zimbabwe and by a new study in KwaZulu-Natal, South Africa. The public health benefits of EBF in low resource settings could be substantial. EBF can be practised by women regardless of their HIV status thus avoiding the stigma of distinguishing infant feeding practice.
Any reduction of HIV transmission due to EBF would simply add to its established benefits for other aspects of infant and maternal health. EBF is unlike replacement feeding, where reduction of HIV transmission has to be carefully balanced against increased mortality due to other infections.
SUPPORT FOR EBF PROGRA-mmes would be strengthened by more rigorous data showing the clear benefits of EBF for HIV prevention.
Discussions of possible mechanisms underlying the benefits of EBF for HIV transmission have focused on inflammation or activation within the infant gut as a result of the introduction of foreign antigens, contaminants and pathogens.
The researchers speculate that there may be additional processes including elevations in breast milk viral load as a result of decreased frequency of infant suckling.
The researchers' counselling programme encouraged EBF in conjunction with other standard messages related to lactation support, including education about initiation of breastfeeding immediately after delivery, correct breastfeeding techniques, frequent on-demand feeding, and prompt management of breast problems.
Counselling to support lactation reduces the risk of mastitis, which is a strong risk factor for HIV transmission, and it is likely that the benefits of EBF for HIV prevention may depend on these other dimensions of healthy breastfeeding.
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