Promoting Breast-Feeding in the Era of AIDS

Exclusive breast-feeding, that is, feeding with breast milk without adding any other solid or liquid foods, is the ideal method of feeding during the first months of life. Among its many advantages, it offers optimal nutrition and a high level of protection against respiratory and digestive diseases in children, and a reduced risk of a new pregnancy for mothers. Nevertheless, until very recently, no consensus had been reached on the optimal duration of exclusive breast-feeding.

The 54th assembly of the World Health Organization (WHO), held in Geneva from 14 to 22 May 2001, issued a resolution recommending that children be exclusively breast-fed during the first 6 months of life. This recommendation, which resulted from a consensus process, is based on the conclusion that there is already enough scientific evidence in the area of public health in order to change an earlier recommendation, which was to exclusively breast-feed for 4 to 6 months after giving birth (1). Latin America contributed considerably in reaching this new consensus, through the influence of an experimental study carried out in Honduras. This study demonstrated, on the one hand, that children exclusively breast-fed for 6 months grow as much as those who are exclusively breast-fed until the fourth month and subsequently breast-fed and given additional healthy and nourishing semisolid foods (2). That is, the introduction of food other than breast milk to the 4-month-olds did not represent any advantage in terms of growth, despite the high quality of the complementary foods. As a result, it is possible that under real conditions, where the complementary foods could be less nourishing and hygienic than those given in the study, that the introduction of additional foods to the 4-month-olds could adversely affect growth and increase the risk of child morbidity. On the other hand, this same study found that with exclusive breast-feeding for 6 months instead of 4 there was better child motor development (3), and a longer anovulatory period for the mother following delivery (4).

As in almost all the world, the rates of exclusive breast-feeding are very low in Latin America and the Caribbean (5). This situation has raised doubts about the practicality of recommending a child diet that is practiced so infrequently. However, the recent findings of two experimental studies (6, 7) and one quasiexperimental one (8) demonstrate that breast-feeding counseling given in hospitals (8) and in the community (6, 7) is a cost-effective way of promoting maternal and child health (9), since it noticeably increases exclusive breast-feeding rates. An experimental study in a low-income periurban area of Mexico City (6) compared the frequency of exclusive breast-feeding 3 months after delivery for women who had had and who had not had contact with counselors trained for the study. In comparison to the control group (no contact with counselors), the exclusive breast-feeding rate was five times as high in the group of mothers who had six prenatal contacts, and four times as high in the group who had only three prenatal or postnatal contacts (12% vs. 67% and 50%, respectively (P < 0.001)). The findings of this Mexico City research agreed with those of a quasiexperimental study carried out in the city of Santos, Brazil (8). There, mothers who gave birth in a hospital where there was breast-feeding counseling provided exclusive breast-feeding for 53 days more than those who gave birth in the control hospital, where there was limited counseling. A second experimental study (7), in the city of Dhaka, Bangladesh, found a prevalence of exclusive breast-feeding at 5 months of age of 70% among the mothers who had 15 pre-, peri-, or postnatal contacts with counselors, versus 6% among the women randomly assigned to the control group, who did not receive any counseling (P < 0.001).

The experimental and quasiexperimental studies that explore breast-feeding counseling show that it is highly probable that this assistance promotes exclusive breast-feeding in various social, economic, and cultural contexts. But to be able to design breast-feeding counseling programs it is very important to include the real reasons that many mothers do not breast-feed their children as recommended by WHO, for 6 months exclusively, followed by the gradual addition of nourishing foods prepared hygienically, and without stopping breast-feeding until the child turns 2. In this issue of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health there is an interesting study (10), carried out by McLennan in the Dominican Republic, which tried to identify which community factors hinder breast-feeding, so that mothers reported the causes that they ordinarily do not reveal when the questions are direct and personal. That is, the study applied indirect questions to reduce to a minimum the bias of "social complacency," which makes mothers not indicate the real causes of their decision not to breast-feed when they are asked directly why they don’t follow infant feeding practices that the majority of them know are ideal for their children.

That study had an interesting result when questions were asked indirectly, that is, when the mothers were asked about the attitudes or typical behaviors of the women of their community with regard to the breast-feeding. Among the important reasons given in the poor periurban community were the fear that breast-feeding affected the woman’s figure or breast shape, and the lack of a desire to breast-feed. However, when the same questions were asked directly, the mothers gave reasons related to the infant or that the mothers could not control, such as "the child did not want to breast-feed" or "I did not have sufficient milk." This approach has important implications for future studies geared toward understanding the true reasons many mothers do not exclusively breast-feed their children. Such studies are essential to developing cost-effective counseling programs in various socioeconomic and cultural contexts.

As the author of this editorial, I would like to have ended on a happy note concerning the recent major progress in research on promoting exclusive breast-feeding. However, a second recommendation of the 54th World Health Assembly forces me to address the subject of vertical transmission of human immunodeficiency virus (HIV) through breast milk. Specifically, the WHO recommends that research be done on how to prevent or combat this serious problem. According to WHO data, nearly 4 million children in the world have become HIV-infected. Of these infections, 90% have occurred in Africa. There is a relatively high incidence in certain parts of some countries of Central America, South America, and the English-, French-, and Spanish-speaking Caribbean. Of these 4 million children, it is estimated that 3.6 million were infected by the mother in the uterus, in the birth canal, or through breast-feeding (i.e., vertically from mother to child). It is estimated that between 1.2 and 1.8 million of the infected children contracted the virus through breast-feeding, indicating that this practice causes between a third and a half of the mother-to-child vertical transmissions (11).

This situation has led the Centers for Disease Control and Prevention of the United States of America to recommend that HIV-positive mothers not breast-feed their children. However, this recommendation carries serious consequences for developing countries, where the risk that a child who is not breast-fed will die is equal to or greater than the risk of death from mother-to-child HIV transmission. The United Nations Children’s Fund (UNICEF) and WHO have proposed a strategy based on voluntary maternal screening and on counseling programs, so that mothers have the information needed for a well-founded decision (12). Under that strategy one possibility is to offer child formulas and other replacement foods to mothers who are HIV-positive at the time of their pregnancy. Unfortunately, this has not been very feasible in the areas with the highest risk, which is precisely where there is less access to HIV screening and to the clean water and refrigeration needed to hygienically prepare and store the child formula. An argument that has also been used by those who oppose the screening of pregnant women is that in societies where it is habitual to breast-feed, HIV-positive women who do not breast-feed could be identified easily and thus be subject to discrimination.

One possibility that has generated a great deal of interest is that children who are exclusively breast-fed have a lower risk of being infected by breast milk. The hypothesis is based on the fact that introducing foods or liquids other than breast milk at an early age can cause microhemorrhages in the child’s intestinal wall and thus facilitate the penetration of HIV. A recent observational study in South Africa (13) supports this hypothesis, but it is necessary to confirm it through other studies with more rigorous designs before reaching a conclusion. In children of HIV-positive mothers, the cumulative risk of vertical transmission of the virus increases the more that the child is exposed to breast milk. Consequently, it has also been proposed that exclusive breast-feeding be practiced, but that the mother’s milk be replaced completely with other foods when the child completes 3 months of age. In this way, the child benefits from exclusive breast-feeding during a very vulnerable period of its life and also reduces its risk of HIV infection since the breast-feeding is for only a relatively short time, 3 months.

Some observational studies raised major expectations when they suggested that the risk of vertical transmission of HIV from mother to child through breast milk could be reduced through maternal supplementation with vitamin A. Unfortunately, three experimental studies done in Africa a short time ago did not produce the same results (14). It has been documented that pasteurizing breast milk can destroy HIV without greatly altering the nutritional or immunological qualities of the milk. In spite of the favorable implications for breast milk banks, in many developing countries mothers no longer want their children to have breast milk from an unknown source. Furthermore, it’s not always possible to guarantee the proper operation of the milk banks’ pasteurization systems, due to the lack of access to screening tests to confirm the absence of HIV in milk samples, or from problems with electricity or other power sources. Given this, breast milk banks have stopped operating in many hospitals and other institutions.

Antiretrovirals such as azidothymidine (AZT) have been effective in reducing the risk of intrauterine transmission or transmission in the birth canal. However, until a short time ago it was not known if antiretrovirals could also reduce the risk of HIV transmission from breast milk. According to some recent results, giving nevirapine to the mother during delivery and to the child soon after birth can noticeably reduce the risk of HIV transmission from breast-feeding, at a cost of about US$ 4 per treatment (15).

We now better understand the magnitude of the problem of vertical transmission of HIV from breast milk. However, in order to prevent and combat that transmission, we need, among other things, to identify the approaches to primary prevention that produce better results in different societies. Due to the enormous implications that this subject carries for HIV/AIDS programs and for promoting breast-feeding, it is very important that a permanent dialogue be established among all the local, national, and Americas-wide programs related to this area. It is also essential to support studies that make it possible to respond to the following questions:

1. What is the epidemiology of pediatric HIV in Latin America and the Caribbean, including the distribution of the infection in different population groups and of the risk factors for mother-to-child transmission? What percentage of the vertical transmissions occur among mothers who are infected during their pregnancy, and what percentage occur among mothers who are infected when are they breast-feeding, when the risk of vertical transmission from breast milk increases even more? In maternity wards and in rural communities how common is it for women to breast-feed children other than their own?
2. What role does exclusive breast-feeding play in preventing the transmission of HIV to the child? How long should the HIV-infected mother exclusively breast-fed her children?
3. How much access do different populations have to voluntary tests to detect HIV during pregnancy? What role does voluntary screening for mothers play in preventing vertical transmission of HIV? How much information on HIV is available to health workers in the Region of the Americas, and how good is that information? What percentage of HIV-positive mothers change their infant feeding plans when the hazards of transmission and the options they have are explained to them?
4. In various populations how feasible is it for infected mothers to choose such recommended options as using replacement foods that are prepared and stored safely?
5. How can access to antiretroviral drugs such as AZT and nevirapine be increased for infected mothers and their children?
6. What role does the nutritional status of the mother and of the child play in the risk of vertical transmission of HIV? Is there excess malnutrition and maternal mortality among HIV-positive mothers who decide to breast-feed?
7. How can access to effective contraceptive methods be provided for mothers who are advised not to breast-feed?
8. What role can breast-feeding counseling play in preventing mastitis or cracked and bleeding nipples, which can lead to a greater risk of transmitting the virus to the child with breast-feeding?

It is also essential to understand how the HIV pandemic affects breast-feeding patterns among mothers who do not have HIV. On the one hand, the pandemic may have a negative effect at the institutional level. This is because UNICEF and other international agencies, whose earlier initiatives were directed only at promoting breast-feeding, are now concerned about combating the problem of vertical transmission of HIV (12). If for this reason the distribution of child formula is started at the community level or in hospitals, it is possible that HIV-negative mothers will gain access to these products, with the resulting harm to breast-feeding practices. It is also possible that HIV-negative mothers who consider themselves at high risk of infection may decide, on their own or as a result of social pressure, not to breast-feed their children in order to not expose them to the risk of infection. On the other hand, if it is confirmed that exclusive breast-feeding has a protective effect against the vertical transmission of HIV, it is possible that HIV-negative mothers will choose this feeding method as a simple preventive measure. The mothers could also feel motivated to follow safer sexual practices, which would contribute to primary prevention. These areas of research should receive high priority in the Region of the Americas, and approaches such as the one presented in the work by McLennan (10) can be used to help understand what factors lead mothers to breast-feed their children or not to do so in this era of AIDS.

Acknowledgments—The author is grateful for the constructive criticisms and observations on earlier versions of this piece made by Sonia Vega-López, Angela Bermúdez-Millán, Sofía Segura-Pérez, and Rubén Grajeda Toledo.

Rafael Pérez-Escamilla
Professor of Nutrition Science
University of Connecticut
Storrs, Connecticut 06269-4017
United States of America
Rperez@canr.uconn.edu

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