No one replied that this had appeared on Lactnet, so I am posting it. Has
anyone seen this issue of Lancet yet? This came from Ted Greiner.
Subject: First evidence that exclusive breastfeeding does not transmit
HIV
Date: Sat, 7 Aug 1999 00:58:28 +0200
Finally a prospective study has done on mother-to-child transmission of
HIV through breast milk using the correct definition for exclusive
breastfeeding. The study concluded that when breastfeeding is exclusive
the entire time from birth, it does not appear to transmit HIV from an
HIV-positive mother to an HIV-negative baby.
The paper is entitled "Influence of infant feeding patterns on early
mother-to-child transmission of HIV-1 in Durban, South Africa: a
prospective cohort study" and is published in the August 7, 1999 issue
of the medical journal Lancet. the authors, A. Coutsoudis et al., found
that transmission rates among those who were exclusively breast fed from
birth were actually lower at three months than among those not breast
fed at all, and much lower than those breast fed but not exclusively.
Though the difference was not statistically significant for those not
breast fed at all, the authors write that this "raises a possibility
that virus acquired during delivery could have been neutralised by
immune factors present in breastmilk but not in formula feeds."
In any case, infants who were non-exclusively breast fed (receiving
water, tea, juice, milk, solids or other things in addition to breast
milk) suffered statistically higher rates of early postnatal
transmission of HIV. The most likely explanation for this is that
anything except breast milk can damage the lining of the infant's
alimentary tract in various ways. The authors point out that "once the
integrity of mucosal surfaces has been compromised by infection,
allergens or trauma, the passage of HIV-1 across mucous membranes into
body tissues is facilitated."
Obviously more studies are needed, but I see two implications that
emerge
already and should be given serious consideration by UNAIDS/WHO/UNICEF
in
their continued implementation of their new guidelines on HIV and
breastfeeding:
1. In ongoing counselling and pilot testing in poorer areas, much more
emphasis should be placed on an option that so far has received little
attention: exclusive breastfeeding for a few months followed by either
heat treatment of expressed breast milk or rapid cessation of
breastfeeding. Relative risks for morbidity and mortality among infants
not breast fed are much greater in these first months. After a few
months, it is much easier for the child to do relatively well on
homemade formulas or other substitutes more affordable to poorer
families, and the child can better tolerate solid foods.
Also, research should be done to determine what rates of transmission
occur
among women who continue breastfeeding with solid foods after varying
periods of exclusive breastfeeding. For example, after six months or
longer
or exclusive breastfeeding, the child may better be able to tolerate
other
foods and resist infection and thus less gut mucosal injury and
disruption
of immune barriers may occur.
2. The best way to reduce overall rates of postnatal mother-to-child
transmission of HIV in developing countries is to promote exclusive
breastfeeding from
birth for all newborns. Most women who are HIV positive during pregnancy
do not know it and this is not likely to change for a long time in many
countries, for both cultural and economic reasons.
The same issue of Lancet also contains a commentary on this article by
M-L Newell who believes that "further research is urgently needed to
confirm and elucidate the findings" before changing public health
recommendations, but calls for a "re-evaluation of the role of
breastfeeding in the transmission of HIV-1."
Sadly, we have no agreed-upon indicator to tell us how many infants are
"exclusively breast-fed from birth." This is needed to inform policy
makers on the current situation and as a baseline to judge the success
of promotional efforts.
Such an indicator would be easy to obtain data on. In any breastfeeding
survey, whenever a mother says she gave nothing but breastmilk to her
baby in the past 24 hours, the interviewer would ask, "Have you EVER
given anything besides breast milk?"
I recently corresponded with the person responsible for developing the
breastfeeding component of the new Demographic and Health Survey
questionnaire about adding it. Unfortunately, she would not agree to use
it, partly out of fear that the resulting figure would be so low that it
might discourage policy makers from trying to do anything about it.
With best regards,
Ted Greiner
Coordinator
World Alliance for Breastfeeding Action (WABA) Research Task Force
WABA website: http://www.waba.org.br
Personal website: http://www.welcome.to/breastfeeding
________________________
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