I am so glad to see that the thorny issue of HIV and BF is still being
raised. Lois posted about "HIV and Infant Feeding and the new UN policy
that HIV infected mothers be advised not to breastfeed. A point has been
made that more emphasis might be made on infant feeding options other than
that of commercial infant formula". Lois also specifically asks about
wet-nursing.
I do realize that wet nursing is mentioned in the WHO/UNICEF/UNAIDS
Guidelines as a possibility, but we seem to be dragging our heels on this in
this part of the world, and with good reason IMHO. These are some of the
thoughts I have had:
1) Assuming the wet-nurse were to be uninfected herself, would she still be
nursing her own baby? How could we establish the recipient baby's HIV
status? (bearing in mind that *bottle-fed* babies have tested HIV+ 7-90 days
after birth). If the recipient baby was infected, what is the risk of
transmission to the wet-nurse (nipple fissures and thrush being likely to
increase the risk of infection). Furthermore, if the baby was *newly*
infected, i e had become infected during delivery, then would s/he be more
infectious?
2) Equally important, if the wet-nurse became infected, then how would we
advise her about the risk of transmission to her *own* baby? (bearing in
mind 29% of babies of newly infected mothers sero-convert in the same 3
month period as their mothers).
3) If the wet-nurse was not currently lactating, but was to induce lactation
or to re-lactate, then we would still have to ask these questions about her
risk of infection. How many older children or other members of the family
does she care for? i e How many *other* people would be affected if she
were to become infected herself.?
4) How can we be sure that the wet-nurse is *not* infected already? -
bearing in mind the window period for the tests, both ELISA and PCR.
5) How can we be sure that the wet-nurse will not *become* infected during
the time that she is breastfeeding someone else's baby? If a woman is
young/healthy enough to produce milk (either lactating already or inducing
lactation) then is she sexually active? If so, then she and the recipient
baby are at risk. It would seem tragic to encourage an HIV+ mother not to
breastfeed her own baby only to have the baby infected by a wet-nurse. In
Harare (capital of Zimbabwe) up to 40% of all women attending ante-natal
clinics are HIV+. This is a high number. IMHO it would not be stretching
things too far to extrapolate this to the general population of sexually
active women.
6) I see the dilemma as needing *different* solutions to two different
populations of babies (a) babies of mothers who have tested HIV+ before
delivery, and (b) orphans.
7) For babies in the category (a) above whose mothers have tested HIV+ but
the status of their babies, of necessity, remains unknown at delivery, the
recent international multi-centre pooled analysis of late postnatal MCT of
HIV-1 infection (Lancet 1998; 352:597-600) showed that the risk of
transmission which could be attributed to *breastfeeding* was only 5% (only
49 of 902 breastfed babies became infected 2.5 - 6 months after delivery).
If 1.5 million babies die each year of other infections from *not* being
breastfed, whereas only 600,000 who were breastfed die of HIV (and how many
of those were actually infected in utero, or during delivery?) then is it
not safer to *continue breastfeeding*?????
8) For orphans, then we need to think again. My own opinion - after much
pondering - is that the best choices, in order of preference, would be
heat-treated EBM (if donors could be found), or failing that, formula.
9) I cannot see how the other methods of "replacement feeding" mentioned in
the WHO/UNICEF/UNAIDS Guidelines can be considered without being tested - I
am speaking of fluids like cow's milk, goat's milk, sheep's milk, buffalo
milk, camel milk, home-prepared soy milk. Of course, if you happen to keep
a camel in your back yard and can go out and milk it every 1 1/2 - 3 hours,
all well and good, but even if mothers/carers can afford them and obtain
them, how can they store other milks without refrigeration? And, what about
the nutritional content/suitability of these milks for the human infant? I
think we all agree, don't we? that if the babies *we* work with are
absolutely unable to receive their own or banked human milk, then formula is
the next best thing?
10) Other suggestions for replacement feeding that are being considered
include porridges/gruels made from maize-meal, millet, sorghum, vegetables,
etc. with or without packets of (commercially-prepared?) vitamins and
minerals. "Replacement feeding" of milks/substances other than formula may
seem very attractive to cash-strapped governments who can pass this
recommendation on to individual families/communities and then forget about
them, without the ongoing bother and expense of obtaining and distributing
formula. But although hungry babies would probably eat mulligatawny soup if
we offered it, while we currently promote "no solid foods for 4 - 6 months",
how can we realistically endorse these types of replacements? Where babies
have mothers it is disturbing and frustrating that almost anything is seen
to be safer for them than what nature intended, their own mothers' milk.
12) I think we *really* need to ask whether the risk of dying of HIV via
breastfeeding is *greater* than the risk of dying from being fed any of
these unphysiological and nutritionally inadequate liquids. Do we not need
to be mindful of who stands to gain if breastfeeding is abandoned? Who is
providing the funding to any organizations (or for individual research
grants) who are involved in the studies showing that breastfeeding is
"risky", and/or the development/implementation of any guidelines which imply
that breastfeeding should be abandoned in favour of another kind of
food/liquid. What kind of track record do these individuals or
organizations have in supporting breastfeeding in the past (or currently)?
Who are they connected to, and/or who is advising them? What do they really
KNOW about it? Or have they just suddenly become interested in the subject
since the comparatively recent possibility of commercial gain (individual or
corporate) has reared its ugly head?
Sorry! Feeling cynical tonight as it becomes increasingly apparent that so
many are climbing on to this particular bandwagon ...
Pamela Morrison IBCLC, Zimbabwe
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