Dear Helen
Lovely to see you on Lactnet. I agree with you it has been known for
several years that heating breastmilk to 62.5 degrees Celsius for 30 minutes
(Holder pasteurization) will inactivate HIV. I believe this is the current
protocol used by the HMBNA, and was reported in March 1993 by Orloff et al,
Inactivation of human immunodeficiency virus type I in human milk: effects
of intrinsic factors in human milk and of pasteurization. J Hum Lact
9(1):13-17.
I would like to comment on your post where you set out the right to choose,
".. WHO/UNICEF/UNAIDS documents on HIV and Infant Feeding since 1998, and...
our new HIV and Infant Feeding Counselling: a training course published in
English and soon to be out in French and Spanish. These documents stress the
right of the HIV positive woman to learn all of the various feeding options
open to her (including exclusive and continued breastfeeding, exclusive
breastfeeding stopping earlier than she might do if HIV negative, and also
including the home heat treatment of her expressed breastmilk by boiling..."
I am starting to look more closely at the wording and phraseology contained
in these documents. Firstly, throughout, breastfeeding is to be promoted
for all HIV-negative mothers and mothers whose HIV status is unknown, but
the HIV+ mother has the right to "learn" about "infant feeding options" and
she is to be "encouraged" or even "helped" to make "infant feeding
decisions". It becomes apparent that "options", "choices" and "decisions"
are *only* used when the possibility of *not* breastfeeding is being
introduced and when breastmilk substitutes/replacements/alternative feeding
methods are to be considered. So that, in effect, the phrase "infant feeding
choice" has become a euphemism for formula-feeding. If you're going to
breastfeed, you breastfeed, but if you're *not* going to breastfeed, you
"choose". Do you see?
Secondly, in much of Africa the whole concept of *choice* about infant
feeding is an entirely novel idea because - certainly in Zimbabwe, and the
other countries where I have lived like Kenya, Uganda, Tanzania, and Malawi
- breastfeeding is universal and alternatives to breastfeeding are virtually
unknown. At a recent meeting where I had the chance to speak with nurses
who are counselling HIV+ mothers we talked about the difficulties that
Zimbabwean mothers have in making such choices, in particular the fact that
the African mother does *not* have the right to make such an important
decision on her own. One nurse laughed in response to my question asking who
makes the choice, and said that you only discover this if you start talking
to the mother about *not* breastfeeding! There are nasty cultural beliefs
and implications for the mother of the rare baby who will not/cannot
breastfeed and when this happens the baby's father, the mother's
mother-in-law and the mother's mother are the ones who will decide, not the
mother. Furthermore when someone in a white uniform starts talking about
infant feeding choices, when no-one has ever heard of such a thing before,
then this may be seen as a *recommendation*, not an option.
But to change tack, you ask "Can mothers really hand express all the milk
their baby needs for about six months, without ever expecting to put the
baby to the breast? Are there cases demonstrating how long a milk supply of
about 700 ml per day or more can be provided using non-electric means alone?
Morrison of Zimbabwe collected some cases of non-breastfeeding lactation a
while back, which she kindly shared with UNICEF New York. However, most
had used electric pumps, and these are not going to be a solution that can
be readily employed in large scale programmes.
1) I am always looking for new cases that used only hand expression to
get all the baby's milk.
2) May I also learn from LactNet correspondents who have had
experience with mothers using non-electric foot pumps or hand pumps to
get all the baby's milk for six months or so?"
Helen, looking through my notes about this, I see that in June 1998 I wrote
to Lactnet, asking for case-histories or anecdotal reports of long-term
pumping or expressing - specifically if mothers were able to exclusively
feed their babies on their own expressed breastmilk for the first 4 - 6
months of life.
Twenty-two Lactnetters were kind enough to send me the most amazing case
histories of mothers who had pumped or expressed for very long times, with
permission to share with UNICEF. Someone also sent in the URL to an entire
site/listserv that was dedicated to the pumping mother, full and part-time,
at http://www.enscript.com/pump.
I sent all the messages (22 in all) to you on 22nd September 1998. I've just
made a little table to look at the numbers and circumstances. The case
histories described long-term hand-expressing or pumping for *at least* 48
babies. In addition to these 48, three respondents said they had worked
with "many", "numerous" and "several" mothers who had provided expressed
breastmilk to their babies for extended periods. The reasons why the
mothers breastmilk-fed, rather than breastfed direct, included a couple of
mothers who didn't "like" breastfeeding, others who had big nipples, flat
nipples or inverted nipples. Baby problems included severe latching
difficulties, sucking problems, being premature (one was born 5 months
pre-term and her lowest recorded weight was 392g, there were also several
sets of prem twins, and one set of prem triplets), cranio-facial anomalies,
including several cases of cleft palate, neuromotor difficulties, congenital
heart defect, and a medical condition combined with severe food sensitivity.
The mothers expressed for periods ranging from 6 weeks to 17 months. Some
expressed for only one baby after successfully breastfeeding the first.
Others expressed for several consecutive babies. Many described exclusively
breastmilk-feeding for the first six months but one exclusively
breastmilk-fed her baby daughter for 17 months!!! Most mothers started out
expressing or pumping 8 - 10 times in 24 hours, and then as time went on,
were able to provide enough EBM for their babies with reduced pumping
frequency. One mother was able to pump only twice each 24 hours with a
mini-electric pump, and obtain >20 oz each time! Another pumped for 30
minutes every 8 hours. After lactation had become well established most
mothers only needed to pump/express 4 or 5 times each 24 hours in order to
obtain enough EBM.
Many of the mothers did use double electric pumps, but at least 8
hand-expressed, 3 used manual pumps and others just "pumped" (with the type
of pump not being specified). The overwhelming majority of mothers that I
work with here use manual expression or manual breast pumps, because no-one
sells the fancy electric ones in this country! However, Helen, you will
recall that one of the requirements contained in the BFHI is that all
mothers will be shown how to manually express their milk, and that mothers
and staff alike are to be assessed on this point. I have some very fond
memories gathered during several BFHI Assessments, of male lab technicians
and doctors and even security guards clutching their white
lab-coats/uniforms to their flat chests and giving me wonderful
demonstrations of correct manual expression technique and I feel sure that
WHO and UNICEF would not have included the requirement for mothers to be
shown how to manually express their milk if it could not be done.
Furthermore my observation of mothers in the neonatal units of hospitals in
Harare is that they can become extremely adept at hand expression of
breastmilk in a very short time when the milk is required by their premature
and sick babies. Manual expression of breastmilk is not difficult, working
mothers tell me that with a little practice, they can hand express 120 ml in
10 minutes.
Perhaps we could persuade you to return to Harare for a week or two to
observe how mothers can accomplish this in the neonatal units at Harare
Hospital, the Avenues Clinic and the Baines Avenue Clinic. As you know,
once the technique is mastered and once lactation is well established (at
about a month), the breasts need only to be well drained to go on producing
copious quantities of breastmilk for months and sometimes even years.
Pamela Morrison IBCLC, Zimbabwe
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