|October 30, 2002|
Volume 4, Issue 35
|Midwifery Today E-News|
“HIV & Breastfeeding, an Update”
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THIS WEEK'S ISSUE
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Quote of the Week
"Research has shone bright lights on what women have always known: Dynamic systems are sensitive to start-up conditions. Thus, a gentle birth is life enhancing for the human organism."
- Robin Lim
The Art of Midwifery
I find the double-hip squeeze to be very effective at relieving back pain and discomfort at the end of latent stage and transition. Hot rice socks and cold back wraps are also sought-after comfort measures. The lap squat is great for supporting moms without tiring their bodies.
- KarieAnn, doula
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A study of British children suggests that women who have an infection or take antibiotics during pregnancy are more likely to have a child with an allergy-related condition such as asthma, hay fever or eczema. Researchers at the University of Nottingham evaluated the medical records of nearly 25,000 British children and their mothers. The study found that children exposed to antibiotics in the womb had a higher risk of developing asthma, hay fever and eczema than did children whose mothers did not take the medication during pregnancy. Because a person's immune system develops while he or she is still in the womb, some experts speculate that factors that modify microbial exposure at this time may have a long-term effect on the risk of developing allergic disease.
- Amer. J. Respiratory and Critical Care Med.,
HIV and Breastfeeding: An Update
At the International AIDS 2002 conference, breastfeeding by HIV-positive mothers received much attention in the maternal to child transmission (MTCT) discussions. According to figures published by the Centers for Disease Control (CDC), every day about 800 infants worldwide are infected with HIV via breastmilk. Moreover, bottlefeeding as a replacement feeding method can result in mortality of 2.5 to 20%.
Several HIV transmission-prevention approaches were discussed besides not breastfeeding. One approach is to give babies uninfected at birth prophylactic antiretroviral medication for the duration of breastfeeding. Nevaripine, an inexpensive drug for intrapartum prophylaxis for MTCT, will be given to infants in trials in South Africa. This means that 100 babies will be exposed to the drug to prevent 14 to 15 from acquiring HIV if the nevaripine as a single drug is effective. At present, the long-term adverse effects of the drug on infants are unknown.
Another approach is to treat the breastfeeding HIV-positive mother with highly active antiretroviral therapy (HAART), a combination of three antiretroviral drugs, to decrease the amount of virus in her blood and theoretically in her breastmilk. This approach will also treat the HIV infection in the mother, and if HAART is continued after weaning at 6 months, the treatment may allow her to live longer to raise her child. The amount of the drug exposure through breastmilk is presumably less than if the drugs were given directly to the infant. The main question is whether the drug exposure causes adverse effects in the babies. Again, 100 babies are exposed to possible adverse drug effects to prevent 15 from acquiring HIV. Some data are available for effects of some antiretrovirals on children whose mothers took the drugs during pregnancy. Children of mothers in the 076 trials (stopped in 1994) and exposed to zidovudine are 8 to 10 years old now. Documents available on the Web from the CDC (www.cdc.gov/hiv) give a good summary of what is already known about sequelae from in utero exposure and drug exposure of HIV-positive infants. The CDC is sponsoring studies in Kenya, Malawi and Thailand. WHO/UNAIDS is supporting research at multiple sites in Africa.
Another approach is pasteurization of expressed breastmilk. A small study of four women in Tanzania resulted in four healthy babies at the end of one year. A solar-powered device was developed that can pasteurize any kind of milk without power (wood fire, electricity or gas). This study was presented at the international AIDS conference 2000 in Durban; no further formal discussion about it took place at Barcelona.
Other approaches that were given less attention were trials of active and passive vaccines given to infants, exclusive breastfeeding, early abrupt weaning and various combinations. In Durban, South Africa, an ongoing study is following up on exclusive breastfeeding. In Zambia, an ongoing trial is comparing abrupt versus gradual weaning and the effect on transmission rates.
In my earlier report [E-News 4:22, May 29, 2002] I more fully discussed the study of exclusive breastfeeding and HIV. The results show that at six months infants breastfed exclusively for three months or more have no greater risk of HIV infection than those never breastfed—19.4% in both groups (neither mother or baby received antiretrovirals antepartum, intrapartum or postpartum.) Infants who had mixed feeding of breastmilk and other fluids or formula or foods had a higher risk of infection (24.7%). This is a small study; more research must be done to confirm or refute this data.
In the meantime the WHO, UNAIDS, UNICEF current policies for infant feeding remain as follows: Exclusive breastfeeding should be promoted, protected and supported for six months for women who are known to be HIV negative and whose HIV status is unknown. For HIV-positive women, the use of breastmilk substitutes is recommended where "acceptable, feasible, affordable, sustainable and safe"; otherwise exclusive breastfeeding is recommended for the first six months.
In spite of the fact that all of the trials previously cited are reviewed and approved by US interhospital review boards, I am still saddened that it is African women who are again being asked to take the risks for themselves and their infants to gather information that will benefit women and babies all over the world. Blessings to these women and their babies who will give us more information about this very important issue.
A Web site with good general information about HIV & breastfeeding is linkagesproject.org/pubs.html.
- Nancy Miller, CNM
La Leche League Statement on HIV and Breastfeeding
La Leche League International acknowledges the worldwide challenge of making informed infant feeding decisions when HIV transmission is a consideration. Parents and healthcare providers are urged to weigh the well-known, documented health and emotional benefits of human milk and breastfeeding for both mother and child against the known, documented health hazards of breastmilk substitutes, the rates of childhood illness and death from infectious diseases in the mother's area of the world, and the incomplete understanding of the risk of HIV transmission through human milk. La Leche League International challenges the scientific community to undertake the research necessary to fully define the role of breastfeeding and human milk in HIV transmission and infant protection.
In general, for women who know they are HIV positive and where infant mortality is high, exclusive breastfeeding may result in fewer infant deaths than feeding breastmilk substitutes and remains the preferred feeding approach. While breastfeeding where infant mortality is low may also carry a risk of HIV transmission for infants whose mothers test HIV positive, there is no clear, published evidence that feeding breastmilk substitutes results in lower infant morbidity and mortality in any infants. The social costs of not breastfeeding also must be considered. When a woman gives breastmilk substitutes in a culture where breastfeeding is traditional, her community may suspect that she is HIV positive, potentially putting her at risk for physical abuse, ostracism and abandonment. In most parts of the world women do not know their HIV status, therefore ongoing support of exclusive breastfeeding is most appropriate and much needed.
While current scientific thinking accepts a risk of vertical transmission with breastfeeding in general, research studies that fully define the role of breastfeeding patterns (particularly exclusive breastfeeding and optimal breastfeeding management) and related maternal and child health on HIV transmission have not yet been done. LLLI is not making a recommendation about breastfeeding for HIV-positive mothers at this time due to the inconclusive nature of the research and its various interpretations.
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Forum Talk: Marketing Your Midwifery Business
I'm curious about how and if other midwives market their practices. I currently have an ad in one of our local alternative publications. I also have a Web site. I have attached my business cards to free pregnancy tests. I use the Citizens for Midwifery "Midwifery Model of Care" brochure with my business card attached on the back as my main method for leaving information in places. I encourage my homebirth clients to place their baby's birth announcement in the local paper. Any other ideas? I'm thinking about teaming up with a doula friend and doing a childbirth information night with videos on doulas and homebirth. Have any of you done this? Suggestions, ideas?
- Pamela, CPM, LM
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