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
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.
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.
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.
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.
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.
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.
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.
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).
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
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
compared to Bobo-Dioulasso) were independently associated with a lower
probability of ever breastfeeding.
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.
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
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.
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.
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.
of the study include a large sample size and data prospectively collected at
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.
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.
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