Valerie Finigan, BA (Hons), RM, RN, IBCLC, Dip Midwifery.
Infant Feeding Advisor/Community Midwife, Department of Midwifery, Acute Pennine Trust, Oldham...
The aim of this paper is to promote professional debate around the issues of choice for mothers who are, or who are at risk of being, HIV positive and are keen to breastfeed their babies. The paper is not intended to define best practice.
Every health-care worker has a professional, ethical and statutory duty to 'do no harm'. The UKCC Code of Professional Conduct (1992) states that 'nurses, midwives and health visitors shall act in such a way as to promote and safeguard the well-being and interest of patients/clients. Ensure that no act or omission on his/her part or within his or her sphere of influence is detrimental to the condition or safety of patients/clients.'
For midwives, it could be argued that there exists an ethical and moral duty to try to safeguard the baby from the vertical transmission of HIV infection (human immunodeficiency virus). On the other hand, it may be considered a human right for a family to be allowed to make a fully informed choice about how their infant is to be nourished (Kent, 2000), especially when all the available choices are unsafe in different ways.
The risk of transmission
Without intervention the risk of vertical transmission of HIV in this country is thought to be 15-20% (European Collaborative Study, 1992). In women with recent infection the risks have been found to be even higher with UNAIDS, the joint United Nations programme on HIV/AIDS (1998), reporting a risk of 29%.
Evidence put forward by Lindegren et al (1999) suggests that the risk of HIV transmission can be reduced to between 1% and 2% by taking the following measures
- Treating the mother with antiretroviral drugs such as zidovudine (AZT) during pregnancy
- Treating the newborn with antiretroviral drugs
- Elective caesarean section
- Not breastfeeding.
For mothers who do breastfeed, different risk of transmission rates have been proposed. Studies estimate transmission rates of 5-14% in the presence of established maternal HIV-1 infection (Simonon et al, 1994; Van De Perre, 1995; Morrison, 1999a; 1999b). A meta-analysis by Dunn et al (1992) is the most often-cited study. This paper combines data from a number of studies (some unpublished) and in it the author concludes a similar rate of HIV transmission (14%) as the previous studies. The analysis includes women in Europe who breastfed for four to six weeks.
Coutsoudis et al (1999, 2001) studied three groups of South African babies. These were exclusively breastfed, mixed fed and exclusively replacement fed. The study found that the highest rate of HIV transmission occurred in the mixed-fed group (24.1%) at three months of age. Never-breast-fed babies had a lower transmission rate (18.8%), as did those who were exclusively breastfed (14.6%). The latter two groups had similar transmission rates at three months. The rate of transmission at six months in this study showed that babies who had been exclusively breastfed for three months still had lower rates of infection (18%) than never-breast-fed babies (19%) or mixed-fed babies (26%).
It seems clear that insufficient information is available to estimate the exact association between the duration of breastfeeding and the risk of transmission. However, Leroy et al (1998) feel that the evidence is strong enough to identify a gradual and increasing risk of transmission as long as a child is being breastfed.
UNAIDS states: 'The persistence of maternal antibodies and the presence of a window period during which infection is undetectable using current available technology, make it impossible to determine whether an infant has been infected during the delivery (intrapartum) or through breastfeeding in the period following birth' (1998). This statement suggests that, when sero-positive women breastfeed their infants, it is not possible to differentiate between HIV transmission attributable to delivery and that which results from breastfeeding following birth. However, it is possible to estimate the risks of late postnatal transmission (after three to six months of age) as ranging from 4% to 12% (Ekpini et al, 1997).
How does transmission occur?
The mechanism of infection by breastfeeding is not well understood. Infection may occur through cell-free viruses in breast milk or through cells which themselves are actually infected with the virus. If the latter is true, colostrum might be likely to be more infectious as it is richer in macrophages. On the other hand, Van De Perre (1995) concludes that 'breast milk contains immunoglobulin A (IgA) specific to HIV which protects the infant's immature gut mucosal surface and acts like an 'antiseptic paint'. Breast milk also contains an anti-CD4 binding factor, which may afford the infant protection from infection. CD4 cells are target cells for HIV. Anti-CD4 cells are lymphocytes (a type of white blood cell) and are key in both humoral and cell-mediated immune responses. Their number decreases during HIV infection. In an infant who is already HIV sero-positive this protection might prove valuable in reducing morbidity and mortality.
Reducing the risk of transmission of HIV
The current accepted practice for midwives and health-care professionals is to advise women who have tested positive for HIV to avoid breastfeeding their babies (DoH, 2001a).
The proposed 'safe alternative' for mothers is to formula feed their infants. Some experts, however, question the assertion that this is an unequivocally 'safe alternative' even in developed countries (Minchin, 1998). Artificially fed infants are at greater risk of diseases such as gastroenteritis, inflammatory bowel disease, bronchiolitis, asthma, eczema and diabetes (Howie, et al, 1990; Victora et al, 1989; Piscane et al, 1992).
There is also the added danger of manufacturing errors, incorrect reconstitution and contamination of formula, during or after the manufacturing process. For example, Baumslag (1995) lists some of the infant formula recalls, as follows: in 1994 a formula was recalled because of contamination with klebsiella and pseudomonas and another was recalled in 1993 for glass contamination. More recently, in 2001, one company recalled certain batches of its infant formulas following contamination with botulism (DoH, 2001b).
Formula feeding and breastfeeding by a mother diagnosed HIV positive have each been shown to pose risks. As midwives our role is to inform parents of the available evidence of 'competing risks' (Morrison 1999a and 1999b) and also to inform them of the options which make breastfeeding, or breastmilk feeding safer, if this is the wish of the mother.
Empowerment of parents
It is the mother who is in the best position to decide whether or not to breastfeed, particularly when she alone may know her HIV status and may wish to exercise the right for it to remain confidential.
Raising children involves decision-making. It is a fact of life that every day parents face choices; problems need solving and situations need resolving. Factual information may enable parents to weigh up their options and be empowered to make a decision. Part of the cycle of informed choice is the provision of information by skilled midwives who have knowledge surrounding the benefits of HIV screening, available treatments and who are able to support the woman's decision regarding feeding in an unbiased way that is sensitive to the woman's individual needs.
Safe feeding for HIV-positive mothers
Exclusive breastfeeding is defined as frequent breastfeeding on demand, without giving other foods or drinks, except vitamins or medicines (Langley, 1998). Mixed feeding can be defined as breastfeeding and giving any other liquids (for example, water, juice, tea), solids or milks (formula or animal).
Morrison (1999a; 1999b) and Coutsoudis et al (1999) both suggest that when mixed feeding occurs, the damage to the baby's gut from bovine proteins in artificial milks increases the rates and risk of infection and that therefore mixed feeding may make the baby more susceptible to the virus.
Vnuk (1993) supports this theory and points out that even one bottle of formula can reduce the acidity within a baby's stomach. Therefore, as HIV is an acid-labile virus, a reduction in stomach acidity might enhance the survival of any maternal HIV-1 infected cells.
Coutsoudis et al (1999) recommends that mothers who choose to breastfeed should do so exclusively and should be advised to:
- Breastfeed for a short period of time only
- To rapidly wean from the breast between three and six months, thus providing the benefits of breastfeeding to the baby with a minimal risk of transmission of HIV.
Embree et al (2000) suggest that mothers are informed of the variables that may make breastfeeding more 'risky':
- A mother who sero-converts during the breastfeeding period
- A mother who continues to breastfeed with sub-clinical mastitis, thrush, a breast abscess or cracked or bleeding nipples
- A mother with a high viral load or low CD4 count
- A high viral load in the breast milk itself
- A mother who chooses to prolong the duration of breastfeeding beyond three to six months
- Mixed feeding.
Thus women who choose to exclusively breastfeed will need knowledgeable health professionals who can support them in their chosen feeding method and reduce the risk of transmission by good management of lactation. For example:
- Correct attachment of the baby to the breast
- Frequent emptying of the breast
- The prevention of breastfeeding problems (engorgement, cracked nipples, mastitis and thrush), which have been identified as risk factors for HIV transmission (Coutsoudis, 2000).
It is clearly important that future research is undertaken. In the meantime, UK midwives are left with a set of professional and ethical dilemmas. It is desirable to lower the risks of mother-to-child transmission of HIV both for parents and from a public health standpoint. However, the question arises whether this should mean giving mothers only one feeding option.
The DoH guidance (2001a), while stating that parents should be advised to avoid breastfeeding, also acknowledges that, if women do breastfeed, they should be supported to do so exclusively.
For these mothers other feasible options are available. For example, a mother who wishes to safely give breastmilk to her baby can purchase a personal pasteurisation unit (for £50 from ACE Intermed). Expressing her own milk and heat- treating it to destroy the virus would require no modification of the ingredients, there would be no difficulties with availability, and this would allow the mother absolute control over her baby's food security (Morrison, 1999a; 1999b).
Even though some of the ingredients may be altered, boiled human milk would be physiologically more suited to the human baby than artificial formula (Morrison, 1999a; 1999b). Donor milk from a milk bank is another option, although the availability of milk banks is restricted in some areas of the country. Some families and cultures may find it acceptable to use a HIV-screened wet nurse.
The Department of Health (1998) suggests that we must aim to create a powerful alliance between knowledgeable patients advised by knowledgeable professionals as a means to improve health and health care. This means that health-care professionals must be able to seek and critique current evidence in order to support parents in difficult situations.
Uncertainties arise in many practice situations. This paper highlights one of these. In the current state of our knowledge, perhaps the best we can do is to be honest about the state of uncertainty that exists, and to present the options in a balanced way.
On the basis of information currently available there is no conclusive argument that formula is invariably best for infants of HIV-positive mothers (Kent, 2000). Well-designed research is needed to resolve the major issues that surround this ongoing debate.
The issue of HIV and infant feeding is surrounded by many shades of grey. The only issue that is clear is that everyone involved is looking for the best care of the mother and her infant.
This article was written as part of a modular programme MSc in Midwifery at Salford University.
The author would like to thank Magda Sachs (BFN) and Sarah Davis (Tutor, Salford University) for peer review, advice and support in writing this paper
The Single Bottle Pasteuriser is available from ACE Intermed
Tel: 01264-350508; Fax: 01264-356281.
Baumslag, N. (1995)Milk, Money and Madness: The culture and politics of breastfeeding. Westport, Conn: Greenwood Publishing.
Coutsoudis, A., Pillay, K., Spooner, E. (1999)Influences of infant feeding patterns on early mother-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet 354: 9177, 471-476.
Coutsoudis, A. (2000)Promotion of exclusive breastfeeding in the face of the HIV pandemic. Lancet. 356: 9242, 1620-1621.
Coutsoudis, A. Pillay, K., Kuhn, L. et al. (2001)Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 15: 3, 379-387.
Department of Health. (2001a)HIV and Infant Feeding: Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS (revised September 2001). London: The Stationery Office.
Department of Health. (2001b)SMA Infant Formula Product Recall of Specific Batches. London: Department of Health.
Department of Health (1998)A First Class Service: Quality in the new NHS. London: The Stationery Office.
Dunn, D.T., Newell, M.L., Ades, A.E., Peckham, C.S. (1992)Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet 340: 8819, 585-588.
Embree, J.E., Njenga, S., Datta, P. et al. (2000). Risk factors for postnatal mother-child transmission of HIV-1. AIDS 14: 16, 2535-2541.
Ekpini, E., Wiktor, S.Z., Satten, G.A. et al. (1997)Late postnatal transmission of HIV-1 in Abidjan, Cote d'Ivoire. Lancet 349: 1054-1059.
European Collaborative Study. (1992)Risk factors for mother-child transmission of HIV-1. Lancet 339: 1007-1012.
Howie, P.W., Forsyth, S., Ogston, S.A. et al. (1990)Protective effect of breastfeeding against infection. British Medical Journal 300: 11-16.
Kent, G. (2000)Breastfeeding: A human rights issue? London: Sage Publications/Society for International Development.
Langley, I.C. (1998)Successful breastfeeding: what does it mean. British Journal of Midwifery 16: 5, 322-325.
Leroy, V., Newell, M.L, Dabis, F.(1998)International multicentre pooled analysis of late postnatal mother-child transmission of HIV infection. Lancet 352: 597-600.
Lindegren, M.L., Byers, R.H. Jr, Thomas, P. et al. (1999)Trends in perinatal transmission of HIV/AIDS in the United States. Journal of the American Medical Association 282: 6, 531-533.
Minchin, M. (1998)Artificial Feeding: Risky for any baby. Victoria, Australia: Alma Publications
Morrison, P. (1999aHIV and infant feeding: to breastfeed or not to breastfeed: the dilemma of competing risks (Part I). Breastfeeding Review 17: 2, 5-13.
Morrison, P. (1999bHIV and infant feeding: to breastfeed or not to breastfeed: the dilemma of competing risks (Part II). Breastfeeding Review 17: 3, 11-19.
Piscane, A., Graziano, L., Mazzarella, G. et al. (1992Breastfeeding and urinary tract infection. Journal of Pediatrics 120: 1, 331-332.
Simonon, A., Lepage, P., Karita, E. et al. (1994An assessment of the timing of mother-child transmission of human immunodeficiency virus type-1 by means of polymerase chain reaction. Journal of Acquired Immune Deficiency Syndromes 7: 9, 952-957.
UKCC. (1992The Code of Professional Conduct. London: UKCC.
UNAIDS. (1998A Review of HIV Transmission through Breastfeeding. London: UNICEF, UNAIDS, WHO.
Van De Perre, P. (1995Postnatal transmission of human immunodeficiency virus type-1: breastfeeding the dilemma. American Journal of Obstetrics and Gynaecology 173: 2, 483-487.
Victora, C.G., Smith, P.G., Barros, F.C. et al. (1989Risk factors for deaths due to respiratory infection among Brazilian infants. International Journal of Epidemiology 18: 918-925.
Vnuk, A. (1993Just one bottle. Breastfeeding Review. 11: 8, 358.