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Adequacy of Replacement Milks for Infants of HIV-Infected Mothers

Summary of published research1

Feeding recommendations for infants of infected HIV-mothers in developing countries remain controversial. As HIV can be transmitted to the infant by breastfeeding, the World Health Organisation (WHO) recommends that, "when replacement milk is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended; otherwise, exclusive breastfeeding is recommended during the first six months of life2. However, little is known about the nutritional adequacy and feasibility of the various breastmilk replacement options recommended in related training materials3. A recent study aimed to explore suitability of the 2001 feeding recommendations for infants of HIVinfected mothers in a rural region in KwaZulu Natal, South Africa, especially with respect to adequacy of micronutrients and essential fatty acids, cost, and preparation times of replacement milks.

Nutritional adequacy, cost, and preparation time of home-prepared replacement milks containing powdered full cream milk (PM) and fresh full cream milk (FM) and different micronutrient supplements (2 g UNICEF micronutrient sachet, government supplement routinely available in district public health clinics, and best available liquid paediatric supplement found in local pharmacies) were compared. The costs of locally available ingredients for replacement milk were used to calculate monthly costs for infants aged one, three, and six months. Total monthly costs of ingredients of commercial and home-prepared replacement milks were compared with each other, and considered in the context of the average monthly income of domestic or shop workers. The time needed to prepare one feed of replacement milk was simulated by local HIV and infant training course participants for a rural homestead, without electricity, gas or water but close to a stream and shrubs (1-2 minutes walk away).

When mixed with water, sugar and each micronutrient supplement, PM and FM provided less than half (50%) of the required amounts of vitamins E and C, folic acid, iodine, and selenium and less than 75% of zinc and pantothenic acid. PM and FM made with UNICEF micronutrient sachets provided 30% of the required intake for niacin. FM prepared with any micronutrient supplement provided no more than 32% vitamin D. All PMs provided more than adequate amounts of vitamin D. Compared with the commercial formula, PM and FM provided 8-60% of vitamins A, E, and C, folic acid, manganese, zinc, and iodine. Preparations of PM and FM provided 11% of the minimum recommended intake of linoleic acid and 67% of the minimum recommended ?linolenic acid, per 450 ml mixture.

It took 21-25 minutes to prepare optimally 120 ml of replacement feed from PM or commercial infant formula and 30-35 minutes for the fresh milk preparation. For an infant requiring 6-8 feeds per day, a carer would need 2.5 hours per day to prepare replacement milks, without taking into account time taken to feed the infant. PM or FM costs approximately 20% of monthly income averaged over the first six months of life and commercial formula cost approximately 32%.

The authors conclude that no home-prepared replacement milks in South Africa meet all estimated micronutrient and essential fatty acid requirements of infants aged under 6 months. Commercial infant formula is the only replacement milk that meets all nutritional needs. The authors suggest that revision of replacement milk options given in WHO/UNAIDS/UNICEF HIV and infant feeding training course materials are needed. If replacement milks are to provide total nutrition, preparations should include vegetable oils, such as soybean oil, as a source of linoleic and ?linolenic acids, and additional vitamins and minerals.

Show footnotes

1P.C. Papathakis, N.C. Rollins. Are WHO/UNAIDS/UNICEFrecommended replacement milks for infants of HIV-infected mothers appropriate in the South African context? Bulletin of the World Health Organization, March 2004, 82 (3), pp164-171

2World Health Organisation. New data on the prevention of mother- to-child transmission of HIV and their policy implications: conclusions and recommendations. WHO Technical Consultation on behalf of the UNFPA/ UNICEF/WHO/UNAIDS Interagency Task Team on Mother-to-Child Transmission of HIV. Geneva: World Health Organization; 2001. WHO document WHO/RHR/01.28.

3 WHO, UNAIDS, UNICEF. HIV and infant feeding counselling: a training course. Geneva: WHO/UNAIDS/UNICEF; 2000. WHO document WHO/FCH/ CAH/00.2-4

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Adequacy of Replacement Milks for Infants of HIV-Infected Mothers. Field Exchange 22, July 2004. p4. www.ennonline.net/fex/22/adequacy