Early weaning by HIV-positive mothers needs to be accompanied by nutritional support for infant

Reseachers in Cote D’Ivoire have found that encouraging HIV-positive mothers to cease exclusive breastfeeding altogether by the time their children are six months old greatly increases the risk of stunted growth unless mothers are able to introduce an adequate range of foods to replace the nutritional value of breast milk. The findings, published in the April edition of the journal Pediatrics, suggest that mother and child health programmes which seek to promote exclusive breastfeeding as a risk reduction strategy need to provide nutritional counselling at the time of weaning and may need to provide nutritional support too.

HIV-positive women who do not have access to clean water and formula feed for their infant are advised in most resource-limited settings to breastfeed exclusively and to attempt to wean the infant around six months after birth. These recommendations are the result of several clinical studies that have shown:

• Exclusive breastfeeding carries a lower risk of mother to child HIV transmission than `mixed` feeding, where infants are breastfed but also receive water and other foods.
• The risk of HIV transmission through breastfeeding remains relatively constant after day 28 of breastfeeding, so the longer the breastfeeding period lasts, the higher the risk of HIV transmission.

However early weaning may be counter-productive for the child if breast milk is replaced by poor food sources with a limited range of nutrients, leaving children open to poor growth and infections.

Researchers associated with the DITRAME Plus study in Cote d’Ivoire wanted to find out whether children who were weaned early, following these recommendations, were poorly nourished or at a growth disadvantage. The study did not look at child mortality or morbidity.

Two hundred and sixty HIV-positive mothers were questioned weekly until their children were nine months old (and quarterly thereafter) about what food their children had received in the previous day and the previous week. At each visit infants were classified as exclusively breastfed, predominantly breast fed, mixed fed or formula fed (follow this link for explanations of each of these definitions).

Mothers were taught how to breast-feed correctly and group sessions explained the benefits of exclusive breastfeeding, how to initiate weaning and what foods should be introduced at the time of weaning.

The researchers developed a numerical index which gave points for positive nutrititional practices, including the diversity of foods which infants received after weaning and the frequency of meals containing various food groups.

At four months of age, 39% of infants were receiving mixed feeding, 30% were predominantly breast fed, 8% were exclusively breastfed and the remaining 23% had already been weaned. Of the mixed fed children, 83% were in the process of weaning by this point, and by month 6 virtually all children had ceased breastfeeding.

Fluids other than breast milk were introduced into the diet very soon after birth. Virtually all children not exclusively breastfed had received water within a week of birth, and this was predominantly tap water.

A low feeding score at month 6 was significantly associated with a lower height for age z score at months 12 and 18, and a lower weight for age z score at months 9, 12 and 18, and this finding was not altered when HIV-positive children were excluded from the analysis. Children with a low feeding score at month 6 had a 50% higher risk of stunted growth at any time point between months 7 and 18, leading the investigators to conclude that “feeding practices during the critical period around the weaning process seemed to be a predictor of the child’s future nutritional status.

These findings need to be considered as a best possible outcome, the authors conclude, because all women received breast milk substitutes from the beginning of the weaning process until month 9, all received intensive counselling and the women were required to recall all details of infant feeding at least once a month in a 30 minute interview.

These findings suggest a need for close attention to nutritional support for mothers at the time of weaning, especially if mothers are being encouraged to cease breastfeeding earlier than the local norm.