Magda - you bring up several excellent points,
1) "What I don't know that we have anywhere is any comparison of rates of
transmission for babies *exclusively* breast milk fed where the milk is heat
treated and babies *exclusively* breastfed...The point, I think, is that
expressing and heat treating might turn out to be more problematic in terms
of transmission than direct *exclusive* breastfeeding."
I think several people have wondered about this, ever since the Coutsoudis
results were published. I don't believe this comparison has yet been made
(if I'm wrong, please let me know!) and it would be really *good* to have
this information - to bring us closer to understanding whether the
anti-viral components contained in raw human milk led to a lower
transmission rate than lack of virus in boiled EBM. One of the researchers
(I think it was Orloff) maintained that the anti-viral components contained
in the lipid portion of EBM were not affected by heat. So this raises
tantalizing possibilities.
2) "I guess what I am saying - or asking, if anyone has more info -- is the heat
treatment intervention when used with exclusive use of maternal milk to feed the
baby a studied intervention?"
No, once again, I don't believe that anyone, anywhere, has actually done a
study to see what happens when the babies of HIV+ mothers are fed
heat-treated EBM, nor is it a standard intervention. It is an "idea" whose
time, apparently, has not yet come. Personally I am at a loss to understand
why trials on the feasibility of using formula as a replacement feed are
given precedence over the possibility of using the most logical replacement
- the mother's own EBM.
3) " My understanding would be that the UN recommendations might be based
on the understanding -- before this paper came out -- of high rates of
mother-to-baby transmission which are usually found in studies -- which
would seem, in the light of Cousoudis'work, to be the effect of a *mixed*
feeding regimen."
Correct. Almost no study before the Coutoudis research defined "breastfed"
accurately enough. For instance, the 1992 Dunn meta-analysis, which
policy-makers appear to hold in high regard, included 42 women with new
infections and 1772 women with established infection. The majority of the
women breastfed for 2 - 4 weeks and only 106 women breastfed longer than 6
months. But whether breastfeeding was exclusive, partial, some, hardly any,
whatever, is not stated. When you consider that a baby infected during
delivery will not show positive on an HIV test for anywhere up to 90 days,
and when you add in the new information from the Coutsoudis study about high
transmission rates associated with mixed feeding (some breast, some "other")
it sheds a whole new light on the estimation that "breastfeeding"
constitutes an additional risk of transmission of 14%. Yet, as far as I
know, the UNAIDS recommendations are not going to be changed any time soon.
The intriguing question is - Why Not?
Pamela Morrison IBCLC, Zimbabwe (where we really *need* more answers).
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