Breastfeeding Endorsed: IBFAN Africa Statement on AIDS

Around the world, babies with AIDS are an increasing and tragic concern. So far there is no evidence proving that breastfeeding contributes to this problem. Substitutes for breastmilk, on the other hand, cause thousands of infant deaths every year. Breastfeeding should continue, even in the countries where AIDS has become a major public concern.

Determining the route of transmission and whether an infant is infected or not is often difficult. If a mother is infected with human immunodeficiency virus (HIV) before she gives birth, her baby will test positive of antibodies transmitted through the placenta by the mother which are circulating in the baby's blood. Existing tests do not distinguish between the baby's own antibodies and those he or she carries from the mother, even though the baby may not be infected with HIV. After some months, 50% or more of babies who tested seropositive at birth will test seronegative, indicating that they do not have HIV infection.

Even for adults, testing can be unreliable. A high proportion of cases seeming seropositive after a first screening test have turned out to be negative after a second or third more precise test. This indicates that present testing methods for HIV detection are still far from perfect.

Any woman infected with HIV may find the demands of pregnancy too great, as far as burdening her with the worry that her infection will be transmitted to the foetus. For these reasons. women infected with HIV should be counseled, as they may wish to be protected from conceiving.

Men who are seropositive should also be counsel led regarding how to prevent transmission of HIV to their partners and thus to unborn infants. Provision of such counseling is essential to limiting the spread of AIDS.

However, babies will continue to be born to HIV-infected mothers. What feeding recommendations are appropriate?

Absence of Conclusive Evidence

HIV has been cultured from breastmilk of infected mothers, as also from saliva and other body secretions. However, evidence concerning transmission of the disease by a mother who is breastfeeding her own baby is so far scanty, anecdotal, and inconclusive. Such evidence comes from a few cases in which breastfeeding mothers were given transfusions of infected blood, and it was assumed although not proven that
the mothers had been free of HIV previously.

We do not know if, in the absence of transfusions, breastfeeding by a HIV positive mother can transmit AIDS. The foetus is exposed throughout pregnancy, and during the birth, and these are almost certainly the times of greatest likelihood of transmission from mother to baby. After birth, there is a great deal of continuing intimate contact between mother and baby, with perhaps a minor risk of exposure to the mother's body fluids if the baby's skin is punctured or eczematous.

So conclusive epidemiological evidence in which it can be shown that the mother's milk was the only possible route by which a baby became infected has not been found. Studies are now under way which may in time yield information on AIDS in populations where many babies are breastfed. When these figures are available in a year or two, we shall know better whether breastfeeding in any way increases the risk of AIDS for a child whose mother was already infected during the pregnancy.

What is important to know, at this point, is that many babies born to HIV infected mothers have been breastfed without developing signs on AIDS, and without showing seropositivity after the placentally transmitted antibodies have been eliminated.

Breastfeeding Protects Health

The unique and irreplaceable advantages of breastfeeding are now universally acknowledged. Mother's milk is the only perfect food for each baby. Every known substitute is inferior. Breastmilk provides antibacterial and antiviral factors which help to protect the baby against numerous infective organisms, including those which cause major morbidity and mortality in infants, notably gastroenteritis and acute respiratory infections.

To withhold breastmilk means deliberately increasing certain risks to the baby's health. For the 25 to 50% of infants born to mothers with AIDS who are already infected with HIV before or at birth, withdrawal of the protection afforded by breastfeeding may greatly add to their risks of various infections, which in turn will accelerate their development of AIDS.

Even if substitute feeds are properly mixed and hygienically given in adequate amounts, babies who are denied exclusive breastfeeding from birth to at least four months are at increased risk of illness.

For many children, these illnesses can be fatal. Failure to breastfeed often enough and long enough also contributes to the widespread problem of inadequate birth spacing, the "baby each year" pattern which endangers the health of all children in a family as well as the mother.

Artificial Feeding Augments Risk

The safety of feeding with substitutes for breastmilk (artificial feeding) in most of the world's homes has never been established. Those who manufacture and market these products commercially have sought to influence both health professionals and parents so as to make their use widely acceptable.

But the manufacturers have never proven their safety under the conditions of use most conunon worldwide.

The immediate dangers of feeding infants and young children with any substitute for mother's milk are now thoroughly documented. Even in industrialised nations, increased morbidity is associated with artificial feeding. In less developed nations, outright malnutrition and mortality from artificial feeds are often dramatic.

Thus any use of artificial feeds has a dual risk: the substitutes for breastmilk are in themselves hazardous under many household conditions and their use to replace mother's milk deprives the baby of the natural protective mechanisms found in the breastfeeding relationship.

Research is needed to determine long-term outcomes with breastfeeding and artificial feeding of infants born to HIV positive mothers. How will morbidity and mortality in the first two years of babies fed from birth on artificial milks compare with those of babies given exclusive breastfeeding for four to six months, followed by continued substantial breastfeeding, with no use at all of artificial feeds?

Such studies must be carried out in conditions representative of the majority of the world's families, for whom adequate economic security and extensive medical services are not available, and by whom the substitutes for breastmilk must be purchased at the local market.

Conclusions for Feeding of most Babies

IBFAN stands for the right of women to breastfeed and to make their own informed choices about infant feeding free from commercial influences. All current evidence suggests that initial exclusive breastfeeding (with no other foods or drinks) for four to six months, and continued breastfeeding during the weaning interval to at least 24 months, still deserves the strongest emphasis as the basis of child health in every socio-economic context.

It is unprofessional to base any recommendations for artificial breastfeeding on guesswork as to a mother's probable HIV status. Possible but unverified risk of HIV infection of either mother or child is not an adequate criterion for any recommendation of artificial feeding. No entire groups of mothers categorised by age, parity, race, national origin, sexual history, place of residence, or economic level, should be advised against breastfeeding.

Continued breastfeeding is the child's principal hope of adequate nutrition and healthy development under most conditions, regardless of whether the mother might test seropositive.

Public health policies or health education messages in the media or elsewhere should not associate AIDS with breastmilk. Such messages carry the danger that many women may abandon breastfeeding because they have no way of knowing whether or not they are HIV infected. And even more may absorb a fear-inspired mistaken belief that artificial feeding is safer than breastfeeding, and will not breastfeed even though they are at no risk of AIDS. Thus the greatest care needs to be taken in public education, with stress upon the major means of transmission - sexual activity, blood contact, and in uteroexposure.

Considerations regarding Milk Banking

Caesarean deliveries, preterm babies and maternal or infant illness do not preclude establishment of full lactation by mothers who receive adequate help from health professionals. If a health institution or special care nursery is using substitutes for breastmilk in quantity, this suggests a need to assess and improve its breastfeeding motivations and management programmes. Attention is drawn to WHO document WHO/MCH/NUT/86.1,which concludes that very few infants require breastmilk substitutes for health reasons, and that viral infections trans
mitted transplacentally are not contraindications for breastfeeding. Given the inherent difficulties of milk banking, and the unique adaptations of each mother's milk to her own child's needs, reliance upon banked milk should be replaced wherever possible by improved support for each mother's breastmilk production, and its exclusive use for her baby from birth onwards. If babies nevertheless require additional or replacement feedings, wet nursing or donated human milk are preferable to any artificial feeding product for the majority of babies. Precautions to verify the health of donors are already routine in most facilities. If donors of human milk are screened for HIV, this must be with the utmost care for their right to privacy, their right to full information, and their right to make their own decisions. In addition, donor milk may be pasteurised. Indications so far suggest that treatment of milk for thirty minutes at 62.5 C will render HIV inactive. More research in this area is under way.

When a Mother is Dying

If the mother is dying or has died, wet nursing by a relative is the best long-term choice. This might be an aunt, a grandmother, or another relative who has breastfed. Professional help should be directed to the support of relactation in the selected adoptive mother. Wet nursing by an unrelated foster mother is the next choice, before any use of non-human milk is considered. Attention is drawn to the recommendations of the UNACC Consultative Group on Maternal and Young Child Nutrition titled "Dietary management of infants who are not adequately breastfed." which urges wet nursing. (Food 1 Nutr. Bull., 1980). Removal of any child from his/her extended family of birth is fraught with dangers, and should never be lightly advised nor made a routine policy. Provision of loving and stable care for a small child outside the family context is rarely achieved. The family's continuing right to make all feeding and the child care decisions on a basis of full information must be respected regardless of their socio-economic or educational level. If artificial feeding is considered attention is drawn to the International Code of Marketing of Breastmilk Substitutes, Article 6.5, which stipulates that any instruction in the use breastmilk substitutes must be given only by health workers, and on an individual basis to those family members who need the information. Manufacturers and distributors of products for infant and young child feeding are not disinterested sources of information on HIV and AIDS. WHO, UNICEF, other international agencies and national governments are called upon to ensure that commercial interests do not exploit this unresolved and complex situation. Manufacturers should not imply in any way that use of their products will lessen the spread of AIDS. Any references to HIV or AIDS should be excluded from their communications, both direct and indirect, with health professionals and with the public. Manufacturers and distributors should not use AIDS as a justification for providing free or lowcost supplies of their products in violation of WHA Resolution 39.28 of May 1986.

Source:

ECHO, Issue No. 11, 1989 published by AAWORD, B.P. 3304 Dakar, Senegal