A consensus call “Drop mixed-feeding”

Draft for internal circulation 10 August 2007

A consensus call

“Drop mixed-feeding”

 

 

ecent research shows that it is important to advise HIV-positive women to avoid mixed feeding (breastfeeding plus other foods) their infants, at least for the first six months. This calls for India ’s HIV programme to bring a policy reform and develop a programme response for ensuring exclusive breastfeeding for ALL WOMEN including HIV positive women. NACO should have a better look at the programme component of “infant feeding options” and provide much needed support to HIV positive mothers for whatever is the method of feeding: exclusive breastfeeding or exclusive replacement feeding. Policy and programme should not lead them to ‘mixed –feeding’.

  New research findings

The new intervention cohort study from South Africa calls to drop mixed feeding. Findings of the study published in the Lancet, assess the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding in HIV positive women. The study estimated that risk of acquisition of infection at six months of age via exclusive breastfeeding was 4.04%. Breastfed infants, who additionally received some solids, had 11 times higher risk of infection and if other milk or formula is given along with breastfeeding the risk could almost double. The authors reported that mortality by 3 months of age among ‘replacement fed’ babies was more than double than those exclusive breastfed. This may be due to the fact that solid foods contain complex proteins, which can damage the lining of stomach and cause the virus to pass through. Exclusive breastfeeding reduces the chances of breast infections and inflammation as compared to mixed feeding. Exclusive breastfeeding also protects the integrity of intestinal mucosa making an effective barrier to HIV. Finally, exclusive breastfeeding reduces the risk of breast problems for the mother, which introduction of other foods often cause. Even sub-clinical mastitis is associated with an increased risk of HIV transmission. These findings are significant addition to existing data on risks associated with artificial feeding. The findings also remove the confusion that earlier studies had caused about the transmission risks between 10-20% without distinguishing between the exclusive breastfeeding and mixed feeding as the study made clear groups of the infant feeding types.

  New policy recommendations

The study having looked into the risk of HIV transmission and survival associated with exclusive breastfeeding and other types of infant feeding, now clearly guides on infant feeding policies, and how and in what way a health worker should counsel and support HIV positive women on infant feeding options both in high and low prevalence settings. The study puts safe exclusive breastfeeding as the BEST available option for the mothers to optimize HIV-free survival in low-income settings. Exclusive replacement feeding is next best.  For any of the infant feeding option, women need intensive and continued economic, health care and nutrition support.

  Counseling and support in the new policy

What is infant feeding counselling and support?

In the above-mentioned study, after delivery, all mothers irrespective of their HIV status were visited by the infant feeding counselors at their home 4 times during first 2 weeks and every two weeks after that. They were supported by the specialist clinics based nurses to maintain exclusive breastfeeding, or replacement feeding whichever was the choice of a woman.  These counselors were fully trained using WHO’s skill based training course for HIV and Infant Feeding.

 

In a commentary in the same issue of Lancet, King and Homes state that exclusive breastfeeding is uncommon in most communities and is easily undermined not only by the marketing efforts of infant formula manufacturers but a wide range of traditional and modern cultural beliefs, and poor health-care practices particularly in the health facilities. It is very common to offer other foods and drinks to infants in the first days and weeks of life because of several reasons including anxiety about milk supply or pressures to work outside the home. In the above mentioned study, 82% mothers breastfed exclusively for at least 6 weeks, and 67% for at least 3 months. They received skilled support from well-trained, lay infant-feeding counsellors. Many randomized trials in varied settings have found this approach to be effective. Counsellors need training, management, support, and supervision and health-care services need strengthening to provide this intervention. Health workers should be adequately informed and able to give mothers appropriate help—currently they are not. Furthermore, there is a need for community education to reach all family members especially men and older women, who influence infant-feeding decisions.  This help and support prevents breast inflammation such as sore nipple/cracked nipples/mastitis, which can double up the transmission. The authors stated that these activities also provide opportunities to protect breastfeeding women from becoming infected with HIV particularly when most of times they don’t know their HIV status.  The increased resources now available to prevent HIV infection in children should be invested in ways that also improve maternal and child health in general. But, in actual practice and budgeting, very little is earmarked for promotion of breastfeeding. Investment in promoting, protecting, and supporting exclusive breastfeeding for 6 months has the greatest potential to improve HIV-free child survival in settings with both high and low HIV prevalence.

 

In a recent article published in the American Journal of Public Health. The promotion of exclusive breastfeeding has the potential to reduce postnatal HIV transmission among women who do not know their HIV status and child survival and HIV prevention programs should support this practice.

 

Why should we bother about mixed feeding?

The study points out clearly that exclusive breastfeeding can be supported in the HIV positive women who will further decrease the mixed feeding and risk of transmission of HIV. These findings are very relevant in our country where the population is dominantly of mixed feeders. According to latest NFHS 3 survey, about 46% women are exclusive breastfeeding during 0-6 month and just 23% begin breastfeeding within one hour of birth. True exclusive breastfeeding rates may be much lower if we follow from 0 to 6 months. Infant mortality in India is around 60/1000 live births in the first year of life. It is important to keep in mind these facts while framing feeding guidelines for health personnel to successfully counsel, support and guide individual mothers to make best possible infant feeding decisions.  The findings have a major relevance to all the states of India with high as well as low prevalence. If we can drop “mixed feeding” rates in our populations, the transmission rates will go down and HIV free child survival will enhance. Thus, safe exclusive breastfeeding for the first six months and stopping breastfeeding altogether after that can be the key strategy to reduce the transmission and improve HIV free survival. International Baby Food Action Network (IBFAN) Asia conducted an assessment of India ’s policy and programme on infant and young child feeding counselling and support, as well as HIV programmes and infant feeding and it shows that a lot is needed to bridge the gaps.  IBFAN Asia has also prepared a position statement on HIV and infant feeding giving stress on inclusion of this important aspect of pediatric HIV transmission in the national programs and policies.

 

Recommendations

1.       Create infant feeding counselling and support service

The NFHS 2 (1999) data showed us that there are about 30% mixed feeders at one month, which increases to almost 80% at six months. This would not be much different now, and to drop mixed feeding, infant feeding counseling and support should be a part of programme response. The earlier policy of NACO on infant feeding is “…..Every effort should be made to promote exclusive breast feeding up to four months in HIV positive mothers followed by weaning and complete stoppage of breast feeding at 6 months in order to restrict transmission through breast feeding. However, such mothers will be informed about risk of transmission of HIV through breast milk and its consequences and would be helped for making informed choice regarding infant feeding.”  It should pave way for a policy reform to reflect new evidence and WHO’s consensus.  The WHO recently called an international consultation, HIV and Infant Feeding Technical Consultation. It led to a “Consensus statement, 2006” which emphasizes a need for consistent messages on infant feeding along frequent, high quality counseling. The consensus statement says “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.” The WHO consultation recommended further, “At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, continuation of breastfeeding with additional complementary foods is recommended, while the mother and baby continue to be regularly assessed. All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided.”

2.       Providing explicit programme support of skilled counselling on infant feeding

Based on the recent research findings, we call upon The Ministry of Health to provide explicit programme support of skilled counselling on infant feeding to its policy of exclusive breastfeeding for the first 6 months for all babies. This calls for earmarking funds for ensuring proper “Infant feeding options and support”.

3.       National AIDS Control Organization (NACO) and Ministry of Health and Family Welfare should take following actions:

a.       Policy: HIV policy should be revised to include one of the infant feeding options as Safe Exclusive breastfeeding (which means, exclusive breastfeeding 0-6 months, with intensive infant feeding counselling and support, ART, and counseling regarding when to stop breastfeeding, starting at six months). It should create a budgetary support to this policy.

b.       Programme/services:

§         Ensure family level counselling through home visits by skilled family counselors (3 day training) to maintain the exclusive breastfeeding status for the first six months. The NRHM and ICDS both should use their frontline workers for this purpose.

§         Family level counseling should be supported by specialist infant and young child feeding counsellors at 5 to 10,000 population, or at least a block of 30 villages for referral support and long term sustainability to help mothers who have any breast pathology like mastitis and sore nipples.

§         Similarly in all hospitals above district level, public or private, a specialist Infant and young child-feeding counsellor should be made available. This needs at least 7- day training and nurses would make a useful resource for providing such ongoing support. Doctors who have received similar special training should support them.

§         Support also includes skilled counseling; home visits at least 4 times during first 2 weeks, and then every 2 weeks till six months. For mothers who chose breastfeeding, prevention of breastfeeding problems like sore nipples needs lactation management and support. For mothers who chose exclusive replacement feeding, it requires sustainable supply of formula, education on safe feeding methods, supervision and support such that a mother who changes her mind is helped to relactate and revert quickly to exclusive breastfeeding rather than mixed feeding, and avoidance of stigma etc. (see more details in Table 1)

 

Table: 1.What support is needed for the mothers for practicing infant feeding options if they have any of these   two different choices?

Needs	Exclusive breastfeeding	Exclusive Replacement feeding
Support of skilled health workers/counsellors	Required Skilled counselling and support to practice exclusive breastfeeding and prevention as well as treatment of sore nipples, mastitis, prevention and treatment of breast over-fullness and engorgement etc	Required to teach replacement feeding including hygiene, dilution etc
Home visits	YES 2 visits in a week for first two weeks, preferable daily for first few days, and then every 2 weeks till about 6 months	YES Needs at least 3 visits in a week, preferably daily for first few days, to check for mixed feeding, and to ensure proper and safe replacement feeding.
Resources to ensure Affordability	Nutrition support to mothers (equal to what had to be spent on formula in case of replacement feeding)	Money to buy animal milk or powdered infant formula OR state ensures, resources to treat sick babies, responsive health care system, PLUS Nutrition support to mothers
Monitoring immune status of the mother	Provide appropriate health care to the mother and maintain CD4 count above >200/cmm	Provide appropriate health care to the mother and maintain CD4 count above >200/cmm
Safety	Needs education of family or parents to maintain exclusivity and prevent breast problems	Needs education of family or parents to prevent diarrhea and other killing illnesses
Education about contraception	Lactation Amenorrhea Method helps	To prevent next pregnancy, some contraception is required
Niverapine	YES	YES
Policy support	YES	YES
Health watch and response	For oral thrush, for mastitis, and other breast pathology, does not need a health facility, specialist counsellor can do the job.	For sickness in the baby, diarrhea, pneumonia etc, need treatment in health facility
Skilled IYCF  counsellor	YES	YES
Primary prevention safe sex practices	YES	YES