Module 4

1. Module 4 Infant Feeding in the Context of HIV Infection

2. Module Objectives • Define key infant feeding terms • Describe the key infant feeding recommendations based on National PMTCT Guidelines and Infant and Young Child Nutrition Policy and Guidelines, 2005-2010. • Give an overview of the National Code of Marketing of Infant and Young Child Foods • Give an overview of the Baby Friendly Hospital Initiative Malawi PMTCT Training Package

3. Module Objectives (continued) • Discuss the main infant feeding options in Malawi and their advantages and disadvantages. • Demonstrate step-by-step safe preparation of commercial formula and home-modified animal milk. • Demonstrate steps in infant feeding counselling for HIV-positive mothers. Malawi PMTCT Training Package

4. Unit 1: Overview of Infant Feeding Recommendations Malawi PMTCT Training Package

5. Unit 1 Objectives • Define key infant feeding terms • Describe the key infant feeding recommendations based on National PMTCT Guidelines and Infant and Young Child Nutrition Policy and Guidelines, 2005-2010. • Give an overview of the National Code of Marketing of Infant and Young Child Foods • Give an overview of the Baby Friendly Hospital Initiative Malawi PMTCT Training Package

6. Basic Facts on Malnutrition, Infant Feeding and Child Survival • Poor nutrition is a leading cause of illness in children. • In Malawi, 48% of children under the age of five years are stunted, 22% are underweight and 5% present with wasting. • Poor feeding practices, such as early mixed feeding, inadequate complementary feeding, or poor hygiene are a major cause of low weight, and high morbidity and mortality among children • For mothers who are HIV-infected, counselling and support may lead to improved infant feeding practices that may also prevent MTCT. Malawi PMTCT Training Package

7. Overview of Infant Feeding in the Context of HIV • Breastmilk is the ideal nourishment for infants, for the first six months of life. • ARV therapy and prophylaxis substantially reduce MTCT. However, ARV prophylaxis does NOT provide long-term protection for the infant who is breastfeeding. • Without intervention, 10% - 20% of infants breastfed by HIV-infected mothers may acquire HIV through breastfeeding. Malawi PMTCT Training Package

8. Overview of Infant Feeding in the Context of HIV in Malawi • Breastfeeding is practiced by almost 97% of mothers • Exclusive breastfeeding (EBF) for the first 6 months of life is practiced by only 53% of mothers • Most infants are not given timely, appropriate or adequate nutrient-rich and energy-dense foods to complement breast milk from age 6 months to 24 months and older Malawi PMTCT Training Package

9. Key Infant Feeding Terms Exclusive breastfeeding (EBF): • All infant nutrition provided by breastmilk • NO other drinks (not even water) or foods should be given to baby • May receive expressed breastmilk • No pacifiers, dummies, artificial teats • No limits on number of breastfeeds (average 8-12 times in 24 hours) • No limits on length of breastfeed • No mixed feeding Malawi PMTCT Training Package

10. Key Infant Feeding Terms (continued) • Mixed feeding: when infant who is breastfed is also given other liquids, such as water, tea, formula, cow’s milk, or foods such as porridge or rice during first six months of life • Wet-nursing: having another woman (HIV-negative) breastfeed baby • Express and heat-treat breastmilk: removing milk from breasts manually or with a pump, then heating it to kill HIV Malawi PMTCT Training Package

11. Key Infant Feeding Terms (continued) Replacement feeding: • Infant who is receiving NO breastmilk given a diet that provides all required nutrients until age at which he/she can be fed on family foods. • During first 6 months of life, replacement feeding with a suitable breastmilk substitute (commercial infant formula or home-modified animal milk). • After 6 months, other foods should be offered to complement breastmilk substitute. Malawi PMTCT Training Package

12. Key Infant Feeding Terms (continued) Commercial infant formula: • Breastmilk substitute consisting of specially-formulated powdered milk. • Made specifically for infants and sold in shops or provided to HIV-infected mothers who choose not to breastfeed. Home-modified animal milk: • Made from fresh liquid (or full cream powder) animal milk and modified using a standard or specific recipe. Malawi PMTCT Training Package

13. Key Infant Feeding Terms (continued) • Complementary feeding: feeding babies who areolder than 6 months of age foods and liquids in addition to breastmilk or breastmilk substitute. Malawi PMTCT Training Package

14. Infant Feeding Recommendations Mothers who are HIV-negative & mothers with unknown HIV status: • Breastfeed exclusively for first six (6) months of life • After age 6 months and up to 2 years or longer, continue breastfeeding while giving complementary foods. • Encourage women with unknown HIV status to test for HIV • Educate mother about risk of HIV infection during pregnancy or breastfeeding. Malawi PMTCT Training Package

15. Infant Feeding Recommendations (continued) Mothers who are HIV-infected: • EBF is a primary feeding option and is recommended during the first months of life • To minimize HIV transmission risk, early cessation of breastfeeding recommended at 6 months or sooner • Avoid breastfeeding when replacement feeding is AFASS. • All HIV-infected mothers should receive infant feeding counselling Malawi PMTCT Training Package

16. Infant Feeding Recommendations (continued) • Ensure use of breastmilk substitutes is in compliance with National Code of Marketing Infants and Young Child Foods • Children 6-59 months receive Vitamin A supplementation • Growth monitoring and health promotional activities • Multimix principle - using foods from different food groups at each meal, making meals more nutritious. Malawi PMTCT Training Package

17. AFASS: Definitions Acceptable: Mother perceives no barrier to replacement feeding. Barriers may be cultural or due to fear of stigma or discrimination. Feasible: Mother (or family) has adequate time, knowledge, skills and other resources to prepare the replacement food and feed the infant up to 12 times in 24 hours. Affordable: Mother and family, with community or health-system support if necessary, can pay the cost of purchasing, preparing and using replacement feeding, including all ingredients, fuel, safe water, soap and equipment, without compromising the health and nutrition of the family. Malawi PMTCT Training Package

18. AFASS: Definitions(continued) Sustainable: The mother has access to a continuous and uninterrupted supply of all ingredients and products needed for safe replacement feeding for as long as the infant needs it, up to one year of age or longer. Safe: Replacement foods are correctly and hygienically stored, prepared, and fed in nutritionally adequate quantities with clean hands using clean utensils, preferably by cups. Malawi PMTCT Training Package

19. AFASS: Possible Questions to Ask Clients Malawi PMTCT Training Package

20. Risks associated with mixed feeding before 6 months of age • The risks include: • Breastmilk is replaced with less nutritious foods. • Increased risk of diarrhoea • Increased risk of HIV transmission to baby due to irritation of intestinal mucosa by other foods/liquids allowing for absorption of the HIV. Malawi PMTCT Training Package

21. Malawi National Code of Marketing of Infant and Young Child Foods • Based on the 1981 International Code of Marketing of Breastmilk Substitutes • Bans promotion of formula feeding and sets labelling requirements • The Code: • Protects and promotes breastfeeding • Supports proper and informed use of breastmilk substitutes • Promotes acceptable marketing and distribution practices Malawi PMTCT Training Package

22. The Baby Friendly Hospital Initiative This is a worldwide effort that aims to give every baby the best start in life by creating a healthcare environment where breastfeeding is the norm. • Goals of BFHI: • To transform hospitals and maternity facilities into breastfeeding conductive environments • To end the practice of distribution of free and low cost supplies of breastmilk substitutes to maternity wards and hospitals. Malawi PMTCT Training Package

23. The Baby Friendly Hospital Initiative: 10 Steps to Successful Breastfeeding • Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff. • Step 2: Train all healthcare staff in the skills necessary to implement this policy. • Step 3: Inform all pregnant women about the benefits and management of breastfeeding. • Step 4: Help mothers initiate breastfeeding within half an hour of birth. • Step 5: Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants. Malawi PMTCT Training Package

24. The Baby Friendly Hospital Initiative: 10 Steps to Successful Breastfeeding (continue) • Step 6: Give newborn infants no food or drink other than breastmilk unless medically indicated. • Step 7: Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day. This allows unlimited contact between mother and baby. • Step 8: Encourage breastfeeding on demand. • Step 9: Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding infants • Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Malawi PMTCT Training Package

25. Unit 2 Infant Feeding Options Malawi PMTCT Training Package

26. Unit 2 Objectives • Discuss the main infant feeding options in Malawi and their advantages and disadvantages. • Demonstrate step-by-step safe preparation of commercial formula and home-modified animal milk. Malawi PMTCT Training Package

27. Breastmilk Feeding Options Breastfeeding Option 1: • EBF & EBF with early cessation Breastfeeding Option 2: • Expressing & heat-treating breastmilk Breastfeeding Option 3: • Wet-nursing Malawi PMTCT Training Package

28. Risks: Breastfeeding & MTCT Mothers who choose to breastfeed should know: • 10%-20% infants breastfed by HIV-infected mothers acquire infection through breastfeeding • ARV prophylaxis does not provide long-term protection to breastfed infant Malawi PMTCT Training Package

29. Risks: Breastfeeding & MTCT (continued) Risk of transmitting HIV to infant during breastfeeding is greater: • When the woman has higher viral load (by clinical or laboratory measures) • When the woman has mastitis, breast abscess or other similar conditions • When the child has ulcers or open sores in the mouth • Possibly, when the mother practices mixed-feeding Malawi PMTCT Training Package

30. Breastfeeding Option 1:EBF Advantages • Protects babies from diseases. • Improved brain growth and development. • Provides all necessary nutrition and water. • Always available/no special preparation • Early cessation ends infant’s HIV exposure through breastfeeding Disadvantages • Risk of MTCT. • Mother needs support to EBF. • Requires feeding on demand 8-10 times per day Malawi PMTCT Training Package

31. Breastfeeding Option 1:EBF with Early Cessation Advantages • Early cessation ends the infant's exposure to HIV through breastfeeding. Disadvantages • Infants malnourishment after breastfeeding stops. • Increased risk of diarrhoea for infants if breastmilk substitutes are not prepared safely. • Infants may become anxious and even dehydrated if stop breastfeeding too rapidly. • Replacement feeding requires feeding infant with a cup. • Mothers' breasts may become engorged and infected during transition. Malawi PMTCT Training Package

32. Breastfeeding Option 2:Expressing & Heat-treating Breastmilk Expressing milk means removing it from the breast, usually by hand. Milk heated to boiling point. Long term strategy • From birth till breastfeeding cessation Short-term strategy: • When mother is symptomatic • When the mother has a breast infection • While the mother is transitioning from breastfeeding to replacement feeding Malawi PMTCT Training Package

33. Breastfeeding Option 2:Expressing & Heat-treating Breastmilk(continued) Mothers should be provided with support: • Taught appropriate techniques for expressing breastmilk • Store expressed breastmilk in a cool place and use within 12 hours if stored at room temperature or 72 hours if refrigerated • Heat only enough milk for one feed. Use heat-treated milk within one hour. Discard left over milk. • Always use a clean cup for feeding the infant. • Express the breast frequently (8 times or more in a 24-hour period) to maintain milk supply Malawi PMTCT Training Package

34. Breastfeeding Option 2:Expressing & Heat-treating Breastmilk(continued) Advantages • HIV killed by heating the milk. • Most nutrients remain in breastmilk after heating. • Others can help feed infant. Disadvantages • May not be as effective (as unheated breastmilk) for protecting baby from other infectious diseases. • Time-consuming and must be done frequently • Baby will need to drink from a cup. • Need safe water and soap to was containers and cups • Need fuel to heat the breastmilk • Others may suspect mother has HIV Malawi PMTCT Training Package

35. Breastfeeding Option 3: Wet-nursing A wet-nurse is a woman who breastfeeds another woman’s baby with consent of the baby’s parent or principal guardian. • Acceptable in some communities, but not in others. • Mothers must receive counselling about potential risk of HIV transmission from a wet-nursing mother who is HIV-infected or a wet-nursing mother whose HIV status is unknown. Malawi PMTCT Training Package

36. Breastfeeding Option 3: Wet-nursing Advantages • Carries no risk of HIV transmission for the baby, as long as the wet-nursing mother is not infected with the virus. • Breastmilk is the perfect food for babies and can protect them from diseases. Disadvantages • Wet-nursing mother must be confirmed HIV-negative. • Wet-nursing mother must be able to protect herself from HIV infection the entire time she is breastfeeding. Malawi PMTCT Training Package

37. Breastfeeding Option 3: Wet-nursing Disadvantages(continued) • The wet-nursing mother must be available to breastfeed the baby frequently day and night. • Small risk HIV-infected infant can pass HIV to wet-nursing mother while breastfeeding. • Others may suspect mother has HIV. • The mother may get pregnant again too soon. Malawi PMTCT Training Package

38. Breastfeeding by Mothers on ARV Therapy • Clear evidence exists that women on ARV prophylaxis and ARV therapy have reduced risk of HIV transmission during pregnancy and labour • Currently no evidence that either ARV therapy or prophylaxis reduces HIV transmission through breastfeeding. • Infant feeding counselling and advice should be the same for all women, whether or not they are/were on ARV therapy or ARV prophylaxis. Malawi PMTCT Training Package

39. Replacement Feeding During First 6 Months of Life • Infants receive no breastmilk • Does not provide immune protection against other diseases. • During first 6 months of life, replacement feeding should be with suitable breastmilk substitute (commercial infant formula, home-modified animal milk with micronutrient supplements). • After six months, suitable breastmilk substitute should be complemented with other foods. Malawi PMTCT Training Package

40. Replacement Feeding Option 1: Commercial Infant Formula Advantages • No risk of transmitting HIV to the infant. • Includes most nutrients an infant needs. • Others can help feed infant. Disadvantages • Does not contain protective antibodies • Infant more likely to get diarrhoea, chest infections and malnutrition • Mother must stop breastfeeding completely, or the risk of transmitting HIV will continue. • Expensive Malawi PMTCT Training Package

41. Replacement Feeding Option 1: Commercial Infant Formula Disadvantages (continued) • Safer preparation requires fuel & clean water. • Others may suspect mother has HIV. • Must be made fresh for each feed. • Continuous, reliable formula supply required. • Baby must drink from a cup. • Mother may get pregnant again too soon. Malawi PMTCT Training Package

42. Commercial Infant Formula Requirements in First 6 months Malawi PMTCT Training Package

43. Replacement Feeding Option 2: Home-Modified Animal Milk • Animal milk that is diluted and enriched to ensure nutritional suitability for infants. • Modifications include diluting milk with boiled water in precise amounts to reduce formula's concentration and adding sugar to increase the number of calories in the milk. • Fewer micronutrients than commercial formula. • Baby should take micronutrient supplement Malawi PMTCT Training Package

44. Replacement Feeding Option 2: Home-Modified Animal Milk(continued) Not all milks are suitable for use in home-modified animal milk. Suitable Milks • Fresh cow’s milk • Fresh goat’s milk • Fresh sheep’s milk • Full-cream milk (pasteurized) • Ultra high temperature (UHT) milk • Full-cream milk (powdered) • Evaporated (unsweetened) milk Malawi PMTCT Training Package

45. Replacement Feeding Option 2: Home-Modified Animal Milk(continued) Notsuitable: • Fresh animal milk already diluted by an unknown amount • Skimmed milk or low-fat milk powder • Sweetened or condensed milk • Thin cereal-based gruels or porridge • Fruit juice, teas, sugar drinks, or sodas • Flavoured milk drinks or coconut milk Malawi PMTCT Training Package

46. Replacement Feeding Option 2: Home-Modified Animal Milk(continued) • Important to observe strict hygiene in preparing the milk. • Should be used within 2 hours or 24 hours if stored in refrigeration at 5˚C or less. • Should only be considered when commercial formula not available or not affordable. Malawi PMTCT Training Package

47. Replacement Feeding Option 2: Home-Modified Animal Milk Advantages • No risk of HIV transmission. • May be less expensive than commercial formula and is readily available if the family has milk-producing animals. • Can be used when commercial formula is not available. • Other family members can help feed the infant. Disadvantages • Does not contain antibodies, which protect infants from infection. • Hard for babies to digest and does not contain all the nutrients that babies need. • Needs to be mixed with water and sugar. The baby will need a micronutrient supplement. Malawi PMTCT Training Package

48. Replacement Feeding Option 2: Home-Modified Animal Milk Disadvantages (continued) • Higher risk of diarrhoea, chest infections and malnutrition. • Mother must stop breastfeeding. • Need to make fresh for each feeding, unless refrigerator available. • Baby needs about 15 litres of milk per month for first 6 months. Sugar and a micronutrient supplement also needed • Baby will need to drink from a cup. • Clean water needed to prepare formula and soap to wash the baby’s cup. • Others may suspect mother has HIV • The mother may get pregnant again too soon. Malawi PMTCT Training Package

49. Replacement feeding 6-24 months • After six months of age, milk alone not adequate for baby’s nutritional requirements. • Introduce complementary foods gradually in addition to: • For HIV-negative or those with unknown status: breastmilk • For HIV-positive: replacement feed if AFASS (or breastmilk if not AFASS) Malawi PMTCT Training Package

50. Replacement feeding 6-24 months (continued) For mothers for whom replacement feeding is AFASS, this means: • Commercial formula: prepared as instructed on the tin. • Fresh animal milk: boil milk. Do not dilute and do not add sugar; the child will need an iron-containing supplement. • Powdered or evaporated milk: add clean boiled water according to the directions on the tin to make full strength milk. Do not dilute and do not add sugar; the child will need an iron-containing supplement. • Processed/pasteurized or UHT milk: no preparation needed; if it has been open more than an hour, it will need to be boiled. Do not dilute and do not add sugar; the child will need an iron-containing supplement. • Do not use condensed milk as the main source of milk. Malawi PMTCT Training Package