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 HIV-

infected 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 The HIV virus is not likely to enter the infant’s body
through the mouth cavity, unless that cavity is
cell-associated HIV damaged (e.g., thrush, lesions).

• factors affecting viral 2. stomach

load:
As the infant’s digestive function is immature,
• stage of mother’s especially before 6 months of age, components of
HIV progression mother’s breast milk serve as protection against
[primary infection and disease. Most of the cell-free HIV is probably killed
later stages of HIV and
before entering the lower digestive tract (i.e.
intestines). Mixed feeding is particularly
AIDS both cause high dangerous, as it does not offer similar protection
viral load in breast milk] and allows for damage to the intestinal mucosa.
• mastitis of the breast
[causes higher viral 3. small intestine
load in breast milk] Damage to lining of the intestine (mucosa) may
• abrupt weaning create entry points for HIV into the infant’s body.
Exclusive breastfeeding protects the mucosa
[causes high viral load from damage.
in breast milk] Diagram source: AMA, 1999.
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

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

5.8
6

4.1 0-1 mo
4
2-3 mo
2.5
1.8 4-5 mo
2 1.4 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

Estimated # HIV infections + deaths at 24 months/1000 live births

Deaths Plus HIV Infections 500

450
400
350
300 BF 24
250 RF 24
200 EBF 6
150
100
50
0
0 50 100 150
Infant Mortality Rate

Piwoz & Ross, Journal of Nutrition, 2005

 What is the infant mortality risk
from not breastfeeding?
12
Pooled Odds Ratios Ghana
10

Lowest tercile of
8 mat. education

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 Non-
breastfed Children 6-24 Months of Age:
http://www.who.int/child-adolescent-
health/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 • Exclusive breastfeeding is

feeding is acceptable, recommended for HIV-infected
feasible, affordable, women for the first 6 months of
sustainable and safe, life unless replacement feeding
avoidance of all is acceptable, feasible,
breastfeeding by HIV- affordable, sustainable and safe
infected mothers is for them and their infants before
recommended. that time.

• Otherwise, exclusive • When replacement feeding is

breastfeeding is acceptable, feasible, affordable,
recommended during the sustainable and safe, avoidance
first months of life. of all breastfeeding by HIV-
infected 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 HIV-
exposed 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
Tedgreiner@yahoo.com

Thank you