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

Session 4:Session 4:Infant and Young Child Feeding Infant and Young Child Feeding and HIVand HIV

Nutrition Management with HIV and AIDS: Practical Tools for Health Workers

Session 4: Infant and Young Child Feeding and HIV and AIDSNutrition Management with HIV and AIDS Training

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ObjectivesObjectives

• 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


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Namibia National Policy on Infant Namibia National Policy on Infant and Young Child Feedingand 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


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HIV and Infant Feeding: HIV and Infant Feeding: The DilemmaThe Dilemma


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Mother-to-Child Transmission Mother-to-Child Transmission (MTCT) of HIV(MTCT) of HIV

• Modes of Mother-to-Child Transmission of HIV:• Pregnancy• Labor and delivery• Breastfeeding


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Risk of HIV Transmission without Risk of HIV Transmission without PMTCT InterventionsPMTCT 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


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Factors Affecting MTCT through Factors Affecting MTCT through Breastfeeding 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)


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Feeding Options for HIV-positive Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1Mothers 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


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Feeding Options for HIV-positive Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1Mothers and Their Partners: OPTION 1

• Exclusively breastfeed for 4 months, followed by early cessation and switch to replacement feedings


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Exclusive Replacement MilkExclusive Replacement Milk

• Advantage• No risk of HIV transmission to the baby


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• 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


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Exclusive BreastfeedingExclusive 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


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• Disadvantage• Risk of HIV transmission to the baby


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• 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


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Replacement MilkReplacement Milk

• Assess home and community situation:• Acceptable• Feasible• Affordable• Sustainable• Safe


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AcceptableAcceptable

• 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


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Feasible (Possible)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


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AffordableAffordable

• 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


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SustainableSustainable

• 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)


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SafeSafe

• 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


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• Must be exclusive (only breast milk)• No water, tea or porridge • Stop breastfeeding abruptly, when

replacement milk acceptable, feasible, affordable, sustainable, and safe (AFASS)


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““Mixed Breast Feeding”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


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Breastfeeding ManagementBreastfeeding 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


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Breastfeeding and HIVBreastfeeding and HIV

• Counsel on abrupt stopping at 4 months

• How to transition to replacement feeding

• If replacement feeding is not AFASS at 4 months


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Counselling on Abrupt Counselling on Abrupt Stopping at 4 MonthsStopping 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


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TransitioningTransitioning

• Steps for successful transition from breastfeeding to replacement milk:

1. Express breast milk and provide feedings by cup between regular feeds

2. As the infant begins to accept cup feeding, replace breast feedings with cup feedings one feed at a time

3. 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


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If Replacement Milk is Not If Replacement Milk is Not AFASS at 4 MonthsAFASS 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


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HIV Testing for InfantHIV 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


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Counselling 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


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Infant feeding counselling for women who are HIV-positive counselling flowchart

From WHO PMTCT Generic Training Package, 2004, p. 4-23

Step 3 Explore with the mother her home and family situation.

Step 4 Help the mother choose an appropriate feeding option.

Step 5 Demonstrate how to practise the chosen feeding option.

Provide take-home pamphlet/brochure.

How to practise exclusive breastfeeding

How to practise other breastmilk options

How to practise replacement feeding

Step 6 Provide follow-up counselling and support. Repeat Steps 3-5 if the mother changes her

original choice.

Explain when and how to stop breastfeeding early

Postnatal Visits Monitor growth. Check feeding practices and

whether any change is desirable.

Check for signs of illness.

Discuss feeding for infants 6 to 24 months.

Step 2 Explain the advantages and disadvantages of different feeding options

starting with the mother's initial preference.

Step 1 Explain the risks of MTCT.


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Infant FeedingInfant Feeding

• Risk-Benefit of feeding options must be considered

• Discuss all risks and benefits of each option with mother and her partner

HIV

DiarrhoeaPneumonia


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Challenges and Barriers for Challenges and Barriers for Health WorkersHealth Workers• What challenges or barriers do you expect

to have in implementing infant feeding recommendations?

• How do you think these challenges can be resolved?


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Challenges to Effective Implementation Challenges to Effective Implementation of Infant Feeding Guidelinesof 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


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Group QuestionsGroup 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?


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Introduction of Complementary FoodsIntroduction 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


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Complementary Foods: Complementary Foods: How Often and How Much?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


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Examples of Appropriate Examples of Appropriate Complementary FoodsComplementary 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


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Strategies to Prevent Malnutrition Strategies to Prevent Malnutrition and Promote Good Nutritionand 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)


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Nutritional Issues in the HIV Nutritional Issues in the HIV Infected ChildInfected 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


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Feeding a Child During IllnessFeeding 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


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Goals of Infant and Young Goals of Infant and Young Child FeedingChild 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


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Maternal Health and NutritionMaternal 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


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Role PlayRole Play


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Case StudyCase Study


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Key PointsKey Points

1. Counsel and support mothers and their partners on infant feeding options

2. If choice is replacement feeding,• Stress exclusive, give no breast milk during this time• Must be AFASS

3. If choice is breastfeeding,• Stress exclusive• Abruptly stop at 4 months or when AFASS

4. Add complementary foods at 6 months5. Stress good maternal nutrition through pregnancy and

after birth

Documents

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