TerriAnn Shell asks: "Why are we recommending that mothers with HIV not breastfeed, when maybe we can suggest having the mother pasteurize the milk, if she desires to breastmilk feed?" She and many others are of course right that if you can't give breastmilk fresh, heat treated may be the next best choice.
Since 1998, the UNAIDS consortium of WHO, UNICEF, and 4 other UN agencies has stated that hand expressing breastmilk and pasteurising it at home (by scalding, bringing to the boil) is an option that should be offered to all HIV positive women. Training for health workers in this option is provided in the WHO/UNICEF "HIV and Infant Feeding Counselling: a training course" materials. Since 1998, three other methods of pasteurising under home conditions at about 60 degrees Celsius have been developed. If "we" in any country are not offering this option to mothers, that omission diverges from the UN guidelines.
But let's be clear that hand expressing and heat treating breastmilk at home requires resources and procedures that are not easy for every household, especially where electricity, gas cookers, refrigerators, kitchen tables and even running water are absent. Here is a summary from a side-session organised by ILCA and UNICEF on May 10th (at UN, New York).
Resources needed by household:
Breastmilk knowledge: how and how often to hand express, how to store and heat treat
Storage: safe storage for expressed milk before treatment, storage for treated milk if not used immediately
Preparation facilities: adequate fuel for heat treatment, adequate water, soap for utensils, hands, clean surface (clean cloth to cover utensils?)
Extra time: time to hand express 20 minutes, 8 times a day; time to heat treat milk (several times a day?)
How does the mother manage the feeding?
Preparation: Mother washes hands, cup washed with soap, water; utensils and fire/paraffin stove/charcoal stove are prepared
Hand expressing: Mother expresses both breasts, removing enough milk to stimulate ample production; probably 8 times in 24 hours
Heat treating: Mother brings milk to a boil/ or puts 150 ml milk in Jar, stands in 750 ml water just off the boil, lets stand for 30 minutes/ or mother uses another pasteurising method for 30 minutes.
Cooling: Milk stands at ambient temperature or in water to cool it to about 30? degrees Celsius
Feeding technique: Infant is fed with cup
Interaction and end: Infant is held throughout feed, mother interacts lovingly during feed, infant finishes milk, (Non of feed is kept to give later)
Adequacy of milk feeds: correct number and amount of breastmilk feeds for age or weight; suitable other milk is given if breastmilk production is insufficient
Age-appropriate feeding: under 6 months, only milk is given; over 6 month, milk and complementary foods are given.
We may need to advocate very vigorously for women to have all the resources they need for this home processing which I estimate to be needed for about 2000 milk feeds during the first year.
In this HIV crisis, there are no easy answers!
Helen
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