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Centers for Disease Control and Prevention.

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When should a mother avoid breastfeeding? Atlanta, GA. Retrieved from www. World Health Organization HIV transmission through breastfeeding: A review of available evidence.

CROI: Treat Mothers to Reduce Breast-Milk HIV Transmission

Quigley, M. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study.

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Pediatrics , , e—e Chien, P. Breast milk and the risk of opportunistic infection in infancy in industrialized and non-industrialized settings. Advances in Nutritional Research , 10 , 69— Breastfeeding and childhood obesity: Shift of the entire BMI distribution or only the upper parts?

Obesity Silver Spring , 16 , — Brandtzaeg, P. Mucosal immunity: Integration between mother and the breast-fed infant. Vaccine , 21 24 , — Chirico, G. Antiinfective properties of human milk. Journal of Nutrition , 9 , s—s. Grummer-Strawn, L. Does breastfeeding protect against pediatric overweight? Pediatrics , , e81—e Newburg, D. Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatric Research , 61 1 , 2—8. Ellis-Petersen, H. How formula milk firms target mothers who can least afford it. The Guardian. Scanlan, M. Battle of the bottle in developing countries.

Why is infant formula use so high in developing countries despite breast being best and what can be done. Global trends in exclusive breastfeeding. The Nutrition Press , January 15, Retrieved from thenutritionpress. Ebrahim, G. Infant feeding in the third world. Postgraduate Medical Journal , 62 ,93— Martin, C. In a subsequent analysis of those data, the prob- ability of transmission through breastfeeding was es- timated to be 0. It should be noted that the probability of infection through breastfeeding per day of exposure was not statistically significantly different for infants of less than four months than for older infants 0.

This is because few replace- ment-fed children become HIV-infected after four weeks. Late postnatal transmission Another way of estimating the risk associated with breastfeeding is to start with infants who had been born to infected mothers and had tested negative for HIV early in life, and to follow them until after they ceased being breastfed, to determine the rate at which they become HIV-infected through breastfeeding. If infants with evidence of not being infected at an early age are taken as the denominator, the rate is estimated from the number of breastfed children who have sub- sequent positive virological tests or persistent antibod- ies beyond 15—18 months or after cessation of breastfeeding.

The time at which the exposure begins is determined by the age at which infants are tested.

In a recent meta-analysis in sub-Saharan Africa of a large number of individual data on breastfeeding and post- natal transmission of HIV from randomized control- Maternal factors RNA viral load in plasma and breast milk The risk of transmission through breastfeeding is probably strongly related to RNA levels in the milk, but the degree of risk has not yet been adequately determined. Limited evidence suggests that RNA vi- ral load in blood is only partly correlated with that in breast milk; and RNA load in breast milk is highly variable between breasts and over time Willumsen, , In a study in Durban, South African women in whom RNA viral load in breast milk was detectable at any time during the first six months post- partum were more likely to transmit than those in whom it was undetectable Pillay et al.

A study in Malawi found that the risk of transmission was in- creased fivefold if RNA virus had been detected in breast-milk samples taken at six weeks postpartum Semba et al. In West Africa, the rate of late postnatal transmission increased 2. According to studies byWillumsen et al. The authors quantified RNA viral load three times in the first three months after deliv- ery, in samples taken from both breasts of lactat- ing women.

RNA shedding varied between breasts and over time. In all, chil- dren were breastfed and HIV-tested. A child was pre- sumed to be no longer at risk of infection once breastfeeding had ceased, and the method used dealt adequately with such censoring. The mean duration of breastfeeding was nearly seven months, and the median, four months. The cumulative probability of becoming HIV- infected after age four weeks was 1.

Factors associated with risk of transmission through breastfeeding There is limited, though gradually increasing, reliable quantification of the effect of risk factors associated with an increased or decreased likelihood of breastfeeding transmission. Many of the factors known to influence overall risk of transmission are also likely to influence transmission through breastfeeding: ma- ternal RNA viral load in plasma and breast milk; HIV- related maternal immune status; breast conditions, including mastitis and abscesses; nutritional status of TABLE 3 Estimated rates of late postnatal transmission Study Age at negative Incidence per Cumulative percentage Cumulative percentage test determining child-years infected by infected at last denominator of breastfeeding 12 months follow-up months Malawi Miotti et al, 1 month 6.

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Together the results of these studies indicate the random na- ture of virus shedding into breast milk. The recent analysis of pooled data from the twoWest Afri- can zidovudine trials Leroy et al. In the Ugandan trial comparing nevirapine with zidovudine Nakabiito et al. Breast conditions Clinical or subclinical mastitis has been associated with transmission risk Semba et al. Subclinical mastitis, which is likely to be more common than clinical mastitis, is not necessarily an infective process and may occur with milk stasis and engorgement of the breast.

In the study byWillumsen et al. Sub- clinical mastitis is more likely to occur when the milk first comes in after birth, when there is inadequate milk drainage as would occur during mixed feeding , or when there is poor attachment, or less vigorous suckling by an ill infant, or during rapid weaning. Whether, at a popu- lation level, treatment of breast lesions results in a re- duction of the rate of transmission through breastfeeding is not clear, and further studies are in progress.

Nutritional status Maternal nutritional status may influence risk of trans- mission overall, as well as breastfeeding transmission. A recent paper presented results from an additional analysis of data from a randomized trial investigating the effect of micronutrients and vitamin A on risk of transmission Fawzi et al. Micro- nutrients excluding vitamin A, given to the mother during pregnancy and breastfeeding, had no effect on the overall risk of transmission, but vitamin A alone was associated with a slight increase of mother-to- child-transmission rates overall, and an increased risk of transmission during breastfeeding.

Micronutrients were associated with a non-significant reduction in breastfeeding transmission and mortality in the first two years of life. The benefit to HIV-infected children was similar to that for uninfected children. These findings confirm the importance of nutritional support for HIV-infected breastfeeding women.


Other studies Coutsoudis et al. Infant factors Integrity of mucous membranes Conditions that damage the mucous membrane of infants, such as oral thrush Candida infection , may be associated with an increased risk of transmission through breastfeeding. It is difficult, however, to de- termine which is cause and which effect, since thrush may be a feature of early HIV-1 infection Ekpini et al. Infant oral thrush can also cause nipple thrush and fissures. Damage to the Mode of feeding may affect the intestinal permeability of the young infant: infants who receive only breast milk may have a less permeable and therefore healthier lining of the gut than those who also receive other feeds.

In the one study carried out to investigate this further, however, feeding mode was not associated with intestinal permeability in in- fants measured with lactulose-mannitol ratios, i. Infants who had been diagnosed with HIV infection at 14 weeks, however, had higher per- meability at six and 14 weeks than uninfected infants Rollins et al. Human secretory leukocyte protease inhibitor Perhaps the best-characterized innate factor consid- ered as protective against mucosal transmission of HIV-1 is secretory leukocyte protease inhibitor SLPI.

However, in a study of 43 unselected HIV-infected breastfeeding mothers in Bangui, with breast-milk samples obtained at one week and one and six months after delivery, the mean levels of SLPI in breast milk of mothers of infants who became infected did not differ significantly from those in the case of infants who remained uninfected Becquart et al. Further controlled studies are needed to confirm the role of maternal and infant SLPI in transmission, either alone or in combination with other innate and specific immune factors.

Mode of infant feeding A factor of particular relevance at population level as regards rates of breastfeeding transmission is mode of infant feeding. In most populations worldwide, breastfeeding is usually initiated, but at an early age is supplemented with water or other drinks or feeds Nicoll et al. In a study in Dur- ban, South Africa, HIV-infected women, after counselling, chose whether to breastfeed or formula- feed Coutsoudis et al.

Those who chose to breastfeed were encouraged to do so exclusively for three to six months. A total of formula-fed from birth and never breastfed, breastfed exclusively for three months or more, and practised mixed breastfeeding. Exclusive breastfeeding carried a signifi- cantly lower risk of HIV infection than mixed breastfeeding Hazard ratio 0.

Further stud- ies are under way to confirm this finding, which has obvious implications for infant-feeding recommenda- tions and for advice to HIV-infected women in set- tings where it is not acceptable, feasible, affordable, sustainable or safe to refrain from breastfeeding. In particular, results from the Zvitambo study in Harare, Zimbabwe, which are imminent, will be of much in- terest J.

Assessment of exclusive breastfeeding is complex, and the results of current studies in Hlabisa, in which mode of feeding is assessed daily for nine months, will shed light on the impact of divergence from exclusive breastfeeding on rate of transmission Rollins et al. Duration of breastfeeding was similar for both sexes, but no infor- mation was available on the age at which other foods were introduced or on type of food.

The sex differ- ence in risk of LPT may be due to males receiving complementary feeds at an earlier age, thus making them mixed feeders, which may have put them at higher risk of becoming infected.

Further research is testing this hypothesis. Preventing transmission from breastfeeding ventions, and ensure continued contact with mothers and infants during the 18—24 months postpartum Temmerman et al.

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Several investigators have attempted to use mathematical models to guide policy- makers in weighing the relative risks and benefits of breastfeeding and other infant feeding options in this context Nagelkerke et al. These models are limited by the scarcity of data on the risks associated with various methods of infant feeding and by the inability of such data to take ac- count of all the factors that influence individual deci- sions about infant feeding. According to current WHO recommendations, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health.

After six months, they should receive nu- tritionally adequate and safe complementary foods while breastfeeding continues up to 24 months or be- yond. Given the need, however, to reduce the risk of HIV transmission to infants while minimizing also the risk of other causes of morbidity and mortality, HIV-positive mothers are recommended to avoid all breastfeeding and use replacement feeding when it is acceptable, feasible, affordable, sustainable and safe to do so. All HIV-infected mothers should receive counselling that includes general information about the risks and benefits of the various infant feeding options and specific guidance in selecting the option most likely to suit their circumstances; they should also have access to follow-up care and support, including family planning and nutritional support WHO, b.

Mixed feeding with both breast milk and other feeds has been associated with a higher risk of HIV infection for the infant than exclusive breastfeeding Coutsoudis et al. The present paper is concerned primarily with this area.