Exclusive breastfeeding hampered by infant illnesses, follow up of mothers with HIV shows

Only one third of women counselled to exclusively breast feed for six months in the Kesho Bora study were able to sustain the practice for at least three months, indicating the challenges of implementing infant feeding advice for prevention of mother-to-child HIV transmission, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

Infant illness in particular was strongly associated with the ending of exclusive breastfeeding (EBF). Boys and infants with neonatal illness (fever, diarrhoea or vomiting during the first month of life) had lower odds of EBF by three months of age [adjusted odds ratio (aOR) 0.48, 95% CI: 0.32-0.73, p<0.001 and aOR 0.54, 95% CI: 0.31-0.93, p<0.05, respectively], Kirsten Bork and colleagues report in this assessment of breastfeeding modes and determining factors.

This illustrates “the challenge of breastfeeding exclusively for six months [in line with World Health Organization (WHO) recommendations] in sub-Saharan Africa despite strong incentives and careful, repeated counselling to an extent which is hardly feasible in routine health care”, the authors write.

The best feeding options for HIV-positive mothers in resource-poor settings have been debated for decades. The risk of HIV transmission through breastfeeding must be weighed against the risk of infant malnutrition, severe disease and death from not breastfeeding. In sub-Saharan Africa this is often not an option. Breastfeeding is the norm; avoidance is difficult. A strong cultural belief in the importance of breastfeeding, widespread poverty, low levels of health care and high rates of infant and child death are the primary reasons.

The Kesho Bora study comprised a randomised controlled trial (RCT) and two prospective cohorts. The RCT was designed to look at the efficacy and safety of a three-drug antiretroviral regimen compared to zidovudine plus single-dose nevirapine for prevention of mother-to-child transmission (PMTCT) during pregnancy, delivery and breastfeeding for women with CD4 counts between 200 and 500 cells/mm³. The two prospective cohorts included women with CD4 counts under 200 and over 500, respectively.

The study was undertaken in Bobo-Dioulasso, Burkina Faso, West Africa; Nairobi and Mombasa, Kenya, East Africa; and Durban and a rural and semi-urban area of KwaZulu Natal (Somkhele), South Africa.

Determinants for starting breastfeeding and for continuing three months after having given birth included socioeconomic variables, CD4 count, trial arm, birth weight and mode of delivery.

Three of the seven antenatal study visits were on feeding choice. Seven comprehensive and extensive postnatal support and counselling planned visits were provided until six months after giving birth. Free formula was provided for infants never breastfed from birth until six months of age and for infants when breastfeeding ceased until six months of age.

Of the 1028 mother-infant pairs 76% (781) started breastfeeding and 56% (565/995) were still breastfeeding three months after delivery (30% exclusively, 18% predominantly and 8% partially).

Exclusive was defined as: no other foods or fluids than breast milk except medicine and vitamin drops; predominant as breast milk and other fluids (water, sugar water, tea, juice) while partial included breast milk plus other fluids and/or foods including formula.

A quarter of women formula fed from birth. Those with CD4 counts under 200, secondary schooling (compared to none), emergency caesarean section and by study site (Durban, Mombasa and Nairobi compared to Bobo-Dioulasso) were independently associated with a lower probability of ever breastfeeding.

The authors note this is the first time a link between gender (male) and lower odds of EBF by three months has been reported. Anecdotal evidence from mothers in Mombasa suggested a widely held belief that boys need more energy, leading to a greater likelihood of introducing other foods early.

Neonatal illness was also linked to lower odds of EBF by three months and has not been reported on before. The authors stress the care taken regarding establishment  of the time sequence of events to avoid reverse causality.

The excess risk for stopping EBF between one and three months of age among ill newborns was significant so the association was not because of non-EBF in newborns weaned from one to three months, note the authors.

The risks of stopping breastfeeding by three months after giving birth were lowest in Bobo-Dioulasso and highest in Mombasa.  While levels of sanitation and socio-economic status can in part explain this difference, the authors suggest national health policies also probably influenced counsellors.

Standard advice in Nairobi was to stop breastfeeding at three months and in both Kenyan sites the child’s HIV status was given at three months, they note, so providing mothers of uninfected children the opportunity to stop breastfeeding. In both South African sites, where proportionally higher numbers of women exclusively breastfed up to six months, information about the child’s status was given 5.5 months after birth.

Strengths of the study include a large sample size and data prospectively collected at short intervals.

The authors mention WHO’s change in recommendations in 2009 that HIV-positive women breastfeeding not needing ART for their own health be covered by combination ART for prophylaxis to the child or the mother until complete cessation. Breastfeeding is recommended to be exclusive for six months and continued for 12 months after giving birth.

This important change was the result of several RCTs (including Kesho Bora) showing a significant reduction in MTCT with the use of ART as prevention. Recent findings among HIV-infected African women of the damaging effect of short or no breastfeeding on child health and survival lend further support.

The authors conclude: “qualitative research is needed to better understand maternal beliefs and perceptions in order to inform and readjust infant feeding counselling and support, with particular emphasis on boys and possibly ill newborns.”

Bork K et al. Infant feeding modes and determinants among HIV-1 infected African women in the Kesho Bora study. Advance online edition Journal Acquir Immun Defic Syndr doi:10.1097/QA1,0b013e318277005e, 2012.