Session 4: Infant and Young Child Feeding and HIV

1. Session 4:Infant and Young Child Feeding and HIV Nutrition Management with HIV and AIDS: Practical Tools for Health Workers

2. Objectives • Define infant feeding options for all mothers (HIV-negative or positive) • Explain advantages and disadvantages of feeding options • Discuss barriers and your concerns about teaching exclusive breastfeed, no mixed feeding, replacement and complementary feedings • List appropriate, locally available, and easy-to-prepare complementary foods to give an infant from 6 months onwards • Explain the importance of nutrition for pregnant or lactating women

3. Namibia National Policy on Infant and Young Child Feeding • As a general principle, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported • Recommend exclusive breastfeeding for first 6 months of life, followed by introduction of complementary foods and continued breastfeeding up to 2 years or more • Breast milk provides best nutrition for all babies

4. HIV and Infant Feeding: The Dilemma

5. Mother-to-Child Transmission (MTCT) of HIV • Modes of Mother-to-Child Transmission of HIV: • Pregnancy • Labor and delivery • Breastfeeding

6. Risk of HIV Transmission without PMTCT Interventions • 300 HIV + pregnant women • Approximately 100/300 mothers (30%) will transmit HIV to infant • 16 through pregnancy • 50 through labour and delivery • 34 through breastfeeding

7. Factors Affecting MTCT through Breastfeeding • Exclusive breastfeeding vs. mixed feeding • Duration of breastfeeding • Mother’s overall health • Recent infection or co-infection in mother • Breast condition: sores or cracked nipples • Condition of baby’s mouth (i.e. cuts or sores)

8. Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1 • Exclusively replacement feed if formula is acceptable, feasible, affordable, safe, and sustainable (AFASS) • Mother should not breastfeed at all during this time

9. Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1 • Exclusively breastfeed for 4 months, followed by early cessation and switch to replacement feedings

10. Exclusive Replacement Milk • Advantage • No risk of HIV transmission to the baby

11. Exclusive Replacement Milk • Disadvantages • Risk of diarrhoea, malnutrition, and infant death if formula not prepared correct • Less bonding between mother and baby • Lack of antibodies found in breast milk leading to more infections • More stigma if replacement feeding is associated with HIV status

12. Exclusive Breastfeeding • Advantages • Promotes bonding of mother and baby • Provides best nutrition • Easy, affordable, safe, always available • Less risk of diarrhoea, malnutrition • Promotes brain development and growth

13. Exclusive Breastfeeding • Disadvantage • Risk of HIV transmission to the baby

14. Exclusive Replacement Milk • Infant formula or modified animal’s milk • When giving animal’s milk, baby will need a daily multi-vitamin and mineral supplement • Cup feed only • Give no breastmilk or other non-milk foods (i.e. porridge drinks) before 6 months • Baby may need water to prevent constipation

15. Replacement Milk • Assess home and community situation: • Acceptable • Feasible • Affordable • Sustainable • Safe

16. Acceptable • Social and cultural factors involved with infant feeding, particularly breastfeeding • Assess if community/home will accept the use of replacement milk without stigmatising or isolating the mother

17. Feasible (Possible) • Help the mother/partner consider the economic, behavioral, psycho-social aspects around replacement milk • Resources and skills are required with this option • Formula must be prepared before every feed, day and night

18. Affordable • Assess if the mother/partner has enough money to purchase formula or milk to prepare at home for up to 1 year • Household needs access to fuel, utensils to boil water and feed the baby, and soap to clean all utensils and cups

19. Sustainable • Milk must be prepared for each feed every day and night • Need continuous, uninterrupted supply of formula or milk, utensils, fuel, water, and detergents for up to 1 year • Replacement milk should be exclusive over first 6 months (no breast milk or other foods given)

20. Safe • Need clean water and detergent (soap) to clean utensils before and after every feed • Safe preparation of formula – not over or under-diluted, according to instructions on formula tin • Need to check expiry date of infant formula and fresh animal’s milk

21. Exclusive Breastfeeding • Must be exclusive (only breast milk) • No water, tea or porridge • Stop breastfeeding abruptly, when replacement milk acceptable, feasible, affordable, sustainable, and safe (AFASS)

22. “Mixed Breast Feeding” • When an infant is fed breast milk with other foods or liquids, even water, before 6 months • Increases risk of HIV transmission and other illnesses/diseases • Should be avoided for ALL babies before 6 months, regardless of HIV status of mother

23. Breastfeeding Management • Show the mother: • Correct positioning • Correct attachment • Management of sore or cracked nipples, blocked ducts, mastitis, or breast abscess • Follow-up to check progress • Stress exclusive breastfeeding

24. Breastfeeding and HIV • Counsel on abrupt stopping at 4 months • How to transition to replacement feeding • If replacement feeding is not AFASS at 4 months

25. Counselling on Abrupt Stopping at 4 Months • ASSESS prior to stopping • Acceptance and support from partner, family and/or community • Available, regular and appropriate supply of breast milk substitute • Ability to safely prepare breast milk substitute • Ability to cup feed • Importance of continued physical contact with baby • Strategies to prevent engorgement

26. Transitioning • Steps for successful transition from breastfeeding to replacement milk: • Express breast milk and provide feedings by cup between regular feeds • As the infant begins to accept cup feeding, replace breast feedings with cup feedings one feed at a time • Once all breast milk feeds are accepted by cup, begin feeding only breast milk substitutes (formula or modified cow’s or goat’s milk) • Mother should provide extra comfort to the baby during this time • Support mother as baby may cry and fuss

27. If Replacement Milk is Not AFASS at 4 Months • If the mother is healthy • If she is exclusively breastfeeding • Then continue until replacement milk is AFASS or infant is 6 months and can tolerate unmodified milk and solid foods

28. HIV Testing for Infant • HIV DNA PCR testing to be introduced • Test infants from 6 weeks • Discuss infant feeding options before infant receives test • Re-evaluate infant feeding based on test result • Continue to advise against mixed feeding • HIV-infected babies should continue breastfeeding as per National Breastfeeding Policy

29. Counselling • Provide all information on options • Allow mother and partner to choose • Discuss home situation, family and community/village support • Partner involvement • Support and counselling • Follow-up

31. Infant Feeding • Risk-Benefit of feeding options must be considered • Discuss all risks and benefits of each option with mother and her partner Diarrhoea Pneumonia HIV

32. Challenges and Barriers for Health Workers • What challenges or barriers do you expect to have in implementing infant feeding recommendations? • How do you think these challenges can be resolved?

33. Challenges to Effective Implementation of Infant Feeding Guidelines • Provider’s prejudice given in counseling • Health services inability to deliver appropriate of infant feeding counseling • Common infant feeding practice • Client’s own knowledge and choices • Support from the partner, family, and/or community • Ever-changing recommendations and research on infant feeding and HIV

34. Group Questions • Group 1: If I breastfeed, I will need to eat more food myself to make good milk. I can’t afford this extra food. Would it be better to use formula for the baby instead? • Group 2: If I breastfeed and I have HIV, then my baby may get HIV from the milk. If the baby gets other milk, the baby may get sick and die. How can I decide what to do?

35. Introduction of Complementary Foods • When? 6 months • What? Household staple energy foods and locally available foods plus 2 cups of milk per day • How? Gradually by spoon, feed liquids with a cup

36. Complementary Foods: How Often and How Much? • One to two teaspoons twice a day; gradually increase amount and frequency • One food at a time to avoid confusion • Introduce well-mashed vegetable and fruits, one spoon of one food at a time • Add other food e.g. soft meat, fish, chicken and egg (only yellow) and enrich staple food with oil, fats and nuts at 9 months • Include 2 cups of milk per day

37. Examples of Appropriate Complementary Foods • Soft porridge • Fortify with baobab fruit (powder), mashed beans, pounded dried fish (sift to remove all bones), 1 egg, milk powder, infant formula (add scoop to porridge), or other locally available foods • Mashed vegetables – examples: pumpkin, potato, sweet potato, carrots, well-cooked greens (spinach) • Soft fruits – examples: mango, papaya (paw-paw), banana, guava

38. Strategies to Prevent Malnutrition and Promote Good Nutrition • Nutritious complementary foods and drinks with locally available foods • Ensure adequate nutrient intake • Growth monitoring at each follow-up visit • Referral to hospital if severe acute malnutrition • Prompt treatment and nutrition management for infections (e.g. oral ulcers)

39. Nutritional Issues in the HIV Infected Child • Poor nutrition weakens the immune system, increasing the child’s risk for common infections • HIV infected children are at increased risk of malnutrition because of: • Weaker immune systems due to infection • Inappropriate feeding practices • Household food insecurity • Orphan or vulnerable status • Continue breastfeeding to protect the baby from other infections and prevent malnutrition

40. Feeding a Child During Illness • Encourage caregiver to be patient with child • Encourage (not force) the child to eat, even if not hungry • Continue feeding the child during illness • Feed extra foods once the child has recovered from the illness until she/he has regained lost weight and is continuing to grow at a normal pace

41. Goals of Infant and Young Child Feeding • Provide optimal nutrition for infants and children • Reduce HIV transmission through breast milk • Keep babies healthy, alive, and HIV free • For HIV-infected babies, continue providing extra nutrition care and support

42. Maternal Health and Nutrition • Good maternal nutrition is important for • Infant growth and development • Prevention of MTCT • Promotes adequate milk supply if breastfeeding • Benefits household • Stress family planning and continued safer sex practices

43. Role Play

44. Case Study

45. Key Points • Counsel and support mothers and their partners on infant feeding options • If choice is replacement feeding, • Stress exclusive, give no breast milk during this time • Must be AFASS • If choice is breastfeeding, • Stress exclusive • Abruptly stop at 4 months or when AFASS • Add complementary foods at 6 months • Stress good maternal nutrition through pregnancy and after birth