Saturday, 29 December 2007

Social Services Take Note!

I'm delighted to be able to pass on the news to you, that UK Social Services have had to take a u-turn in the case of Fran Lyon and her unborn daughter Molly.

This news is wonderful on several fronts:

Hopefully, it means Fran can come back to the UK in the future, without wondering if Molly will be snatched at the airport. I'm sure Molly's grandparents will find this of some comfort.

Fran's courage in not only going to the press and fighting her case openly, but the immense courage she showed by leaving the UK, and all her loved ones and possessions, have been shown to be wise and considered decisions.

Social Services have felt the power and strength of those fighting for Fran and Molly, and should be heeding the change in wind: we will not stand for inept, occult and anonymous removals of children from their mothers. There are guidelines - use them!

Those that turn a blind eye to the increasing number of these cases - where children are being removed, or threatened with removal without reasonable cause or due process of the guidelines - will hopefully rethink their complacent position that "there must be more than meets the eye" to this, and always assume Government agencies are acting correctly. Such assumptions do no one any good, least of all the decent and competent Government officials who are as outraged by this sort of stuff as everyone else!

I also hope it will shed more light into the dingy and unsatisfactory Family Courts system.

If we shout loudly enough - they will have to listen. :-)

Personally, I'm delighted for Fran. it will be interesting to see how much wider coverage this story gets in the national press....

Fran, wherever you are - may you have an easy labour and plentiful milk!

Tuesday, 25 December 2007

Away in a manger...

The sharp cold air was fresh on his cheeks. The birth had been so intense, so filled with dread and joy, that he was drained. His beloved had done so well, without anyone but he to help, and he'd heard her praying into the baby's ear when she'd finally lifted him up to her face. God's Love had breathed upon them, all three, he had felt it move through him and fill the air with light. She'd handed the warm and sleepy babe to him, as she moved to make herself more comfortable. His hands had shook, and his heart and soul opened at the warmth that flooded into him, the smell of a newborn filling him with awe. He had felt thunderstruck, far more than he had when the news of the pregnancy had been delivered to him. He knew he would die for this babe, and love it no more than any other that might be delivered of his own loins. The little one had opened a sleepy lid, and his heart had been pierced and remade again, in the second they had looked into each other's eyes.

His beloved had settled back down, and extended her arms. He had gently settled the baby, his Son in God, onto her chest. the baby had nestled there for a moment, them wriggled around, finding his mother's nipple once more. He'd gone to help, to move the baby slightly, but his wife to be had stayed his arm with a gentle smile, and her wisdom reached out to him, just as it had through the birth. All was as it should be, all was as it would be.

Just then the stable door had burst open, and an aged matron from the town finally bustled in, with a young girl in tow. She'd stopped and stared, a huge grin on her face at the sight of the mother and infant finding each other.

"It's here then, everything all right?" Joseph nodded, unable to speak past the lump in his throat. The matron took charge, and he found himself outside in the sharp air whilst orders were given to the young girl, and everything finished with "..and don't disturb that baby as you go!"

He could hear the to-ing and fro-ing inside, as he sat in the silence and considered the stars in the sky, and how the world have been remade and nothing could ever be the same again. Plans began to form, for how best to transport the two people his world now centred upon, for the long journey home. It was bright and clear, far brighter than he thought it should be, and he'd begun to search the skies for the moon, to see just how bright this light could be, when figures drew closer. He shrank inside, hoping there would be no trouble, and relaxed quickly enough when some shepherds smiled and waved their greetings. By the time they were close enough to converse, he'd settled into his role as Proud Father, and he spoke with the whisper of God in his ear, and determined to not be surprised at any events of the night.

The shepherds settled down outside with him, and lit a fire and cooked food and hot drinks, as they awaited the matron's pleasure. Joseph had not realised how tired and hungry he was, and then wondered about Mary...? As if reading his thoughts, the lead shepherd knocked on the stable door, and the matron opened it.

"Not yet, she needs peace for her and the babe." The shepherd nodded, and handed over a cup.

"We collected the herbs fresh, from the hills, as we came down. Made it fresh here, just now. For her milk." The matron sniffed the brew and smiled "You've one or two of your own, to make this that well! She'll be happy with this, I'll be bound." And she closed the door firmly.

Joseph conveyed his thanks to the man, who was rough and gruff and wrinkled from a life outdoors. He shook the thanks away "I've had seven of my own, man, and I know how it feels these first few hours. The herbs were there for the taking, and a newbabe born - what else would we do with them! The mothers hate the drink 'tho, it's bitter... as bitter as her milk will be sweet!" They all laughed and sat around the fire, telling stories of the births in their families, and how their own sons had found their place in the world.

Joseph crept in last, when the door was finally opened to the visitors. Mary was clean and fresh and her sweat ridden hair had dried. The babe was snuggled onto her, the head barely seen over the warm shawl that encompassed them both. Her gaze never left the baby's face. The shepherds sat in quiet wonder, and gave gifts. More herbs, a warm fleece, a new born lamb. Joseph began to allow confusion into his mind, as they all sat in quiet wonder and adored. How could...? What was ...? But the voice of God whispered to his soul again, and he felt the calm acceptance return. Was not every birth a miracle, and should not all babes be worshipped?

His gaze, in turn, never left the sight of his son, peacefully settled upon his mother's breast.

The matron and her apprentice left with the shepherds. "She's a good girl, that one, done well. No problems I could see. The baby is sucking well and all should be well. I'll return when I can." He settled in the hay beside them both, whispering gently as she lifted the sleeping baby this way, then that, marvelling at how he knew how to find his mother's nipple, how to curve upon her breast and fall asleep once more. Somehow, this was so much more special than all the sleeping, feeding and loved babies that he'd ever seen before. So much more special than any other baby who had ever fallen asleep upon his mother's breast.

He dozed slightly, then awoke, as footsteps once more made their way to the stable. His eyes were dazzled by the gold woven into the cloth, his nose and throat flooded with the rich perfume and spiced air that entered. But nothing was richer to him now, than the sight of the mother and child in each other's arms, nothing more sweet to him, than the smell of a newborn nursing upon his mother's milk. Thus he held his own amongst the jewels and silks and marvelled at how well his beloved coped with the richness and wisdom now kneeling at her feet, and the depth of the revere from everyone as they adored the child.

The eldest of the three, spoke to him at length before he left. In absence of another mother to be there, he felt that Joseph should attend in detail to the baby's needs. Joseph nodded, and listened to another long tale of newborns and milk and comfort. Another huge bundle of herbs was pressed into his hands, with directions for making sure the baby was left alone with the mother as much as possible. He nodded, puzzled, for there was a shadow in the face of this king, and fear, well hidden, deep in the folds of this ancient face.

The puzzling did not last for long, as no sooner had their footsteps faded, than light and air filled the scene and Joseph once more was delivered unto the word of God.

He felt he had aged a thousands years in the few moments it took for the message to be passed on. Gazing down at the sleeping mother and babe, their breaths intertwined and their hearts beating as one, Joseph felt such pain and fear grip him as he almost lost his mind. The baby was curled around Mary's body, as if holding onto her heart, his little fists held a few strands of her hair. She was slumbering gently, everything in her attending to the child. The babe would move, she would move. A hand would raise, check him, stroke his cheek, settle him in her arms a little more, and she'd drift off. The thought of any harm coming to this little miracle... the thought of death and pain being wrought against any mother, a newborn torn from her arms.... bad enough, but the thought of this mother, this child... his child.... He fell to his knees and tears fell silently to the stable floor.

He prayed as he packed, prayed as he planned and prayed as he slept at their feet, guarding them against the door. When they rose, the baby was strapped firmly against Mary's chest, so it would be warm and fed and cared for in the miles that lay ahead. Eager to be gone as quickly as the angel had bidden them, Joseph helped Mary up onto the donkey, the warm fleece padding for her to sit on. She was in pain, and tired, but all was well with her and her son, so nothing else mattered.

He gave her the bitter herbs to chew, to keep her sustained throughout the journey, and they escaped Bethlehem without notice. Throughout the long trek ahead, the baby snuggled into the warm folds of flesh, safe from wind and sun, and grew strong from his mother's milk. Love poured from Mary's breasts, into the baby's heart, and the family thrived.

Tuesday, 11 December 2007

Christmas Spirits

It's that time of year again. Town Centres as filled with harassed people rushing to and fro, office parties are packing out the pubs and large pine trees are being stuffed into small cars.

Magazines are filled with advice and hints and tips: how to baste the turkeys, pre-prepare the veg and survive the relatives. Oh yes, and how long to pump and dump for if you are the mother of a breastfeeding baby and off for a night out with the girls.

So how long do you pump and dump for? Answers vary from 12 to 48 hours, depending on the source. Other answers abound, including the seemingly standard one in the UK lower end mags: feed formula whilst you've been drinking.

Because as we know, breastfeeding babies are at risk from alcohol exposure from their mothers having a good night out.

Except we don't know that, actually. What we know is the opposite. What we know, as opposed to what we think we know, is that there are no adverse effects reported on breastfeeding babies whose mothers are drinking alcohol in moderation.

You may be forgiven for not knowing, we know this, as so many sources tell us otherwise. From the aforementioned advice columns, to Government hand outs and your own Health Visitor. Many of them will go on about risk of transfer, liver damage in the infant and reduced motor development in toddlers.

They'll say this, because they read guidelines, and scan to the bottom of them, and see names like "Mennela" and "Little" and think "Oh yes, that's those studies that proved...." and then they'll tell you that the info is correct and You Cannot Have A Drink Like A Normal Person. You Are The Mother Of A Breastfeeding Baby And You Must Suffer For Your Cause.

Complete hogwash. :-) You Are The Mother Of A Breastfeeding Baby And You Too Can Have A Drink If You Want One.

Let's look at why you can go out with the girls and have some Christmas Spirits if you want some:

Both the Menella and the Little studies have been widely discredited. Little actually discredited Little. This is quite important, as this is the 'main' study that stated there was health risks to children for mother's drinking. She did a baby study, and said that babies of mothers who drank alcohol, were one point behind on a scale of motor development at 12 months. One point.

She then redid the entire sequence a few years later, and could not replicate her results. She herself found she was wrong. She couldn't find any difference between breastfeeding babies whose mothers had drunk alcohol, and those who hadn't.

But still, her original research is endlessly quoted as The Reason to restrict mothers of breastfeeding babies in their enjoyment of alcohol.

This link is a nice debunking of both the original studies.  Edit: try this one instead.

So where does this lack of evidence leave us? Well, it leaves us, as always, with us knowing the facts and making our own informed choices.

So what are the facts on breastmilk and alcohol?

Well, simply, your blood alcohol level is your breastmilk alcohol level. And alcohol goes into the blood quite quickly, and leaves at a steady rate. How fast it goes in, depends on your weight and if you have eaten near the time you drank the alcohol.

If you are quite skinny, and had an empty stomach, a glass of wine will hit your bloodstream, and your milk, at its highest point in about 30 minutes. If you are heavier, or had a meal, it could take between 60 and 90 minutes to hit you, with the 60 minutes being the most probable.

So, between 30 and 60 minutes after you swallowed the glass of wine, the highest alcohol rating would be in your milk.

Alcohol filters out via your liver, at the rate of approx one unit of alcohol, per one hour. So, an hour later - no alcohol in your blood, or your breastmilk. None. Zilch. Nada. Zip.

So, if you drink a glass of wine with one unit of alcohol in it - anywhere between 90 and 120 minutes later, it will have disappeared from your blood, and your breastmilk.

If you were binge drinking, and had five units of alcohol in that one quick drink - it would take 5 hours to process out. So, between 5 hours 30 minutes later, and 6 hours later - those five glasses of wine you had within a couple of minutes, would all be gone! Note how unrealistic this is. :-)

Where does this info leave you if you want to go out and party? Well, you have two choices if you've decided you're going to drink. Space the drinks and time the next feed, around the alcohol processing rate, and ensure baby doesn't get a drop of alcohol. This may be important to you if you have a very young baby. Immature livers are immature livers, and a liver that's still growing... it's up to you if you want to introduce any alcohol to it at all. But you can drink some, and make sure your milk is clear of any alcohol at all. Do the arithmetic. Not quite the moment they always told you about in school, where algebra would save your life one day - but another very useful moment in the life of add, multiply and subtract.

If your baby is older, say over 3 or 6 months, and you don't mind it getting a smidgen of alcohol - and that's all it gets, a smidgen - then go ahead and drink. For, although your breast milk has your blood alcohol level, it also has to go into the baby and be digested along with its food (your breastmilk) and only a tiny amount goes through into the baby. In fact, the real issue on you drinking alcohol isn't the alcohol, it's... Are You Safe To Care For The Baby? If you're over the drink drive limit - are you too pissed to be the caregiver? I'd say yes - your mileage may vary, but really, shouldn't you have someone else to bring the baby over for a feed and then take it off you whilst you sleep it off? I think so. :-)

There are two issues, really, with mothers drinking. One minor, one major.

The minor one is... if you've booked the night off, and partner is doing the babysitting, and has some expressed breast milk to feed the baby whilst you're off... be aware your breasts will likely become engorged if you skip too many feeds. Think ahead, plan ahead. Pack extra breastpads, so you can change frequently in case you start to leak. You may want to also pack some old muslin cloths, for if your get too uncomfortable, you can always slip away to the loo , and hand express some milk off into the cloths, then throw them in the bin. A true 'pump' and 'dump'. After all, few mothers go out on the Xmas razz with a breast pump, storage containers and a cool bag in their handbags.

Although, I have seen some seriously big handbags in my time. :-)

The major issue, is if you are a mother who is drinking regularly. Are you exceeding your 14 units per week? Are you having those 14 units is a short space of time (binge drinking)? If you are, you need to look at what you are doing. But not for the baby... for you. For the issue with a mother who is drinking over this amount on a regular basis... is the health of the mother.

Alcohol and health IS a serious issue. I'm not advocating alcohol, I'm advocating informed choice. If you are drinking over the recommended amounts, regularly, you need to look at yourself, and ask some hard questions. Not to satisfy me, or some Government official, or your GP, but to satisfy yourself about what you're doing why you're doing, and if it's an acceptable risk. And it's your risk, and your life. But you do have a baby to think of... because babies do better with healthy mothers. :-)

And also, please note, the discussion of breastfeeding babies and alcohol is completely different that that of being pregnant. Consuming too much alcohol in pregnancy does damage babies. If you are pregnant, you really will need to go out and do the work, and the thinking, for yourself.

So where, does this leave us? Well, it leaves me with a rather nice Shiraz. Whatever your decisions, and your choices, enjoy the season!

(Oh yes, and let's just deal with the formula one shall we? Put it like this.. you've gone out, intending to have a couple of drinks, spaced out over the evening. But, somehow, that went for a burton, and you've staggered in the door so pissed you can barely stand, with your breasts about to explode and wondering where both Hubby, and the baby are. Hubby stands there, holding your hair out of the toilet bowl, whilst you throw up, and you both debate the fact that as you've been gone for several hours longer than you thought, all the EBM is gone. What to do with hungry baby? Utterly pissed mother's breastmilk, or formula? Breastmilk. Less risk. Okay? Glad we cleared that up. :-)

"A mother should not drink alcohol while breastfeeding? Not true! Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers."

Dr Jack Newman

Saturday, 1 December 2007

Breastfeeding Babies and HIV+ Mothers

Today is World AIDS Day. When I was a volunteer in AIDS and HIV+ issues in the early 1980s, we hoped Acquired Immune Deficiency Syndrome would be gone by now. In some senses, it has, as the treatments now available for people with Human Immunodeficiency Virus active in their bloodstreams, are so effective, AIDS itself can be prevented from being developed for years, allowing infected people to live happy, healthy and fulfilled lives.

When no one knew what was going on in the 80s, when people were mysteriously dying of simple infections that were running rampant through their system, the current situation - where both cause and transmission routes are known, and drugs can slow down replication and deal with symptoms - would have been seen as an almost complete triumph. Although this state of affairs doesn't represent a cure, it does, effectively, mean that the disease should be under control.

What we couldn't see back then, although the evidence was there, is that HIV transmission, and the development of AIDS subsequent to infection, would become an economic issue. It would be about resource poor people, in resource poor countries, not about the biology of the infected person.

At the height of the panic in the UK about HIV, when the UK Gov was pushing leaflets with images of giant carved granite headstones through every letter box, who could have seen that HIV and AIDS was going to develop into a major killer of mothers and their children? That poverty, and the diseases of poverty, would feed into the virus, and devastate family life for generations? Looking at it now, I'd like to think that anyone with a modicum of common sense and the slightest understanding of power, could have seen it plainly (and many did so). But it passed me by.

I just couldn't see a world where treatment was available, but not provided as there wasn't enough money, or political desire to do so. Where transmission routes are clearly known, but culture opens the doors to the virus. Where religion can defend behaviour that puts women's lives at risk to their husband's culturally sanctioned promiscuity, but the same religious viewpoint can condemn the wife for trying to protect her own body. I was a naive soul, in the 1980s. 'Patriarchy' was an outdated term, that could not possible apply to the life I, and others, were living.

Oh, it only that were true! For if it was, I doubt very much I'd be making this post today... for there would be no need to highlight the report I'm about to reproduce here for you! No need to point out that the battle ground over HIV is drawn out on the bodies of poor and dispossessed women. That who controls female bodies, and who has a right of access to them, and how that access is undertaken, are cultural issues, and the self-determination of the woman herself is often the last element considered... and that this impacts greatly with HIV status. That women are both continually put at risk of HIV infection, by the cultural status quo around them, and then their behaviour in response to that status proscribed. Women who had have little to no choice on putting themselves at risk of infection, who then have little to no choice on how their bodies are treated post-infection.

Terrible, isn't it? You're sitting there shocked, and sympathetic, and nodding in agreement, aren't you? Absolutely wrong, that the least enfranchised of us have the least control of their bodies, isn't is?

Is it?

Seriously, is it? Do you think women who are HIV+ have a right to control their bodies? Do you think mothers who are HIV+ have a right to determine what they do with that body? Do you, for instance, that an HIV+ woman, who is becoming a mother, has the right to consider allowing her baby access to her breasts? Does the baby of an HIV+ mother have the same right to breastfeeding as other babies? Does the same right of access to the mother's body if the mother desires, apply to her baby? Do you think this?

I do.

Why I think this, is a complex affair, and one that requires careful analysis of culture, from several perspectives. Not surprisingly really, as we're discussing breastfeeding babies, and one thing that's patently clear is that as soon as you discuss them, you have to engage with cultural values that are hostile to a baby's need to nourish at the mother's breast.

So let's unpick some of the reasons why some of you are sitting there shocked, that such a terrible thing has been said - that mothers with HIV+ status should be allowed to make the same feeding choices as everyone else.

To begin with, let's address the nature of the risk. Do you know what the risk of transmission is, to an exclusively breastfeeding baby? What maternal transmission rates are, if the baby is receiving only the mother's milk for the first six months of life, as is the WHO Gold Standard? Well, the transmission rate on those babies is.... 4%.


So 4 in 100 babies, will absorb HIV from the mother. 96 babies out of a hundred, will not do so. Has that shocked you? Were you expecting much higher figures? How many babies did you think become infected, through mother's milk? Where did you get that idea from.....? Hmm... ?

Is 4% too high for you? All right for the 96, but not to good for the 4? Agreed, it would be better if it was zero, I'll give you that.

Of course, it can be zero, or near as damn it. If you treat the mother with anti-viral drugs during the pregnancy and breastfeeding, which costs the same as formula feeding the baby... the transmission rates are so low they are zero in the groups tested - less than one, to be absolutely clear. so, you can have a range of risk for transmission in breastfeeding from 0% to 4%.

Is 4% still simply too high? Are you sitting there thinking "Even at 4 percent, mother's shouldn't be allowed to take this risk with their infant's life." Do you feel it's legitimate to condemn such mothers, and in some cases, separate them from their babies and enforce formula feeding upon them? Do you think Governments should do everything in their power to get the message through to those mothers that they cannot allow their babies to breastfeed? After all, 4 percent of them will become infected!

Well, you are right, 4 percent of them will be. On the other hand... in the resource poor areas, 15% of them will be dead within three months of birth, as a result of the formula feeding. That's 15 dead babies, versus 4 infected babies.

Do these figures seem right to you.. that more babies will die from the formula use, than would have acquired the infection if they are breastfeeding? Does this tally at all, with the news reports, the debates, the general conversations you've heard over the past few years?

Could it possibly be true, that exclusively breastfeeding by HIV+ mothers improves the health of their babies in resource poor areas?

Well, it is true - and the WHO have finally come out and stated so, unequivocally. Shouting to be heard over the clamour of formula marketeers who have made great profit from scaring every one over 'the need to formula feed if you are HIV+' and the cultural frenzy in the resource rich west of the spectre of the 'dangerous breast' infecting innocent babies.

I've appended the report in full at the bottom of this post: do read it. Foot notes are on the original link above.

Now, I've said this is about culture, as much as anything, and have really only spoken about medical research and statistics. Where is the culture? Well, I'm willing to bet it's in the heads of some of the people reading this, who are saying.... "well yes,that's probably okay in those poor places... but the rich West can't afford those 4 babies to be infected, so let's formula feed them when we know the formula is safe."

And the culture there... is... that formula is safe as long as the water and preparing areas are clean.

And this isn't so.

Not only is powdered infant formula not a sterile substance, it can carry bacterial contamination from manufacture, it is potentially harming to the newborn stomach. Simply, newborn gut lining is not designed to ingest cow's milk, no matter how modified it is. The newborn gut is a route of infection, for many infections, if it is compromised by having anything else other than human milk poured into in the first six months of life. It takes six months for the gut to mature on its own, and develop immunities to strange proteins (such as cow's milk) coming into contact with it.

A gut that has had anything other than mother's milk in it, for those first six months, is compromised. That's why formula fed infants, in the resource rich West, with its seemingly stringent hygiene conditions, still have far higher rates of vomiting, sickness, diarrhea and serious stomach infections that those babies who are breastfeeding. Their immune system is compromised by lack of breastfeeding, the formula itself compromises their stomach lining and it often carries bacterial contamination.

But culture states this can't be true... because formula is nice and safe and sterile and scientific, and breastmilk comes out of not nice, unsafe and not scientific female breasts. Infected breasts. Well, they may be infected with HIV, but the milk coming out of them protects and builds the lining of the baby's stomach, and there is evidence to suggest the proteins in human milk destroys HIV. So HIV+ mothers are still doing the best they can by their infant, by letting them breastfeed exclusively. Fewer will die from contaminated formula. Fewer will die from infections taking hold in their compromised gut.

Culture says not, of course. News headlines, campaigns by formula marketeers, everyone who's scared of HIV.. the voices against breastfeeding seem to crescendo when an HIV+ mother enters the room. Science, rational and evidence based research, leaves through the back door. Fear based instinct rules, and the 'obvious' and 'safe''conclusion - prevent the mother from breastfeeding at all costs - emerges. Remove her right to make an informed choice on behalf of her baby, and tell her she cannot nurture her baby at the breast. She isn't allowed to decide which set of risks she wants to apply to her feeding choices: she must choose formula.

My argument is that she requires support, proper information and the freedom to choose for herself and her baby. She may choose formula, particularly in the West, where practices may reduce the transmission rate of HIV to zero. Equally, she may choose to be treated by anti-viral drugs and to breastfeed. The point is, the choice is hers, and we should be doing our damnedest to support each woman in that choice. To make sure their babies can have access to the breast, if the mother wishes it, and that every mother - rich or poor - has the freedom to choose what's best for her and her baby. And that's a choice free from bigotry that demands that HIV+ status automatically means that mother's cannot allow their babies to breastfeed. Today's report finally makes that clear to all and updates the data previously being used to build arguments that deprived breastfeeding babies of their mother's body.

In the wider issues around this, the twentieth World AIDS Day, you may also like to have a look at Nelson Mandela's 46664 site. Self determination is the best way forward for everyone, not just breastfeeding babies! :-)

- - - - - -

WABA World AIDS Day Statement
Press Release
Embargo: 1 December 2007


A decade of uncertainty has fuelled an agonizing dilemma about the least risky way to feed HIV-exposed babies.

Research presented in 2007 finally points conclusively to the need for renewed protection, promotion and supportof breastfeeding. The Final Report of the 2006 World Health Organization HIV and Infant Feeding Technical Consultation1 provides welcome revised recommendations. New evidence clarifies that the most appropriate infant feeding option should continue to depend on a mother’s individual circumstances, her health status and the local situation, but should take greater consideration of available health services. HIV-positive mothers should breastfeed their babies exclusively for the first 6 months of life, and continue partially breastfeeding after 6 months unless conditions are already in place to show that replacement feeding is safe.

Commenting on the dilemma of competing risks between HIV transmission through any breastfeeding vs no breastfeeding, Dr Hoosen Coovadia was quoted this year as saying, “If you choose breastfeeding, you would of course have HIV infection. You would have about 300,000 per year in the world. But if you avoided breastfeeding, the mortality would be about 1.5 million per year. So on the balance of probabilities for poor women in the developing world, there is no other choice than to breastfeed their infants. You shouldn’t devise policies for the rich few. There are some, but the majority of HIV infected women are poor.” 2

His subsequent paper showed that HIV transmission through 6 months’ exclusive breastfeeding by South African mothers was 4%.3 Cumulative 3-month mortality due to replacement feeding was 15.1% vs 6.1% for breastfeeding. Early weaning vs continued breastfeeding substantially increased morbidity and mortality of infected and uninfected babies in Uganda 4, Malawi, 5 Kenya,6 and Zambia 7. Researchers concluded that the risks should be anticipated and PMTCT programmes should strongly encourage breastfeeding into the 2nd year of life. .

Specific HIV and infant feeding counselling was less effective than group information, videos and pamphlets in achieving exclusive and extended breastfeeding in Zimbabwe.8 Intriguingly, 84.5% of mothers recruited into the ZVITAMBO study did not wish to learn their HIV-status, 9 thus avoiding a recommendation for early weaning for HIV-exposed babies, leading instead to an extremely high rate of HIV-free survival.10

Finally, providing antiretroviral therapy (ART) to mothers only during pregnancy and birth begs further scrutiny. While only ~1% of HIV-infected mothers currently receive it, ART for eligible mothers could reduce MTCT in resource-poor settings by over 75%.11 In Rwanda12 and Tanzania13 triple-therapy dramatically reduced transmission of HIV during 6 months exclusive breastfeeding to 0% and <1% class="blsp-spelling-error" id="SPELLING_ERROR_25">iral therapy (HAART) for mothers recruited into the DREAM study in Mozambique, Tanzania and Malawi.14 Acknowledging the difficulty in telling a woman that she can avoid transmitting the infection to her child, but that little can be done for her own health, researchers provided HAART to mothers from the 25th week of pregnancy through 6 months exclusive breastfeeding.

Cumulative HIV transmission to infants was similar to rates reported in high-income countries and lower than those of formula-fed babies, being 2.2% and 2.7% respectively, with postnatal rates of 0.8% and 1.8%.

Political will and strong leadership are needed to reverse the decade-long erosion of breastfeeding accompanying the global PMTCT effort. <BR>

Characterization of formula-feeding as a safe infant feeding option can no longer be justified; contamination of powdered infant formula can occur intrinsically from raw materials, during manufacture 2/2 or from extrinsic sources.15 16 Its cost has been very high in terms of infant malnutrition and mortality, and indisplacement of funding away from treatment for HIV-positive mothers. Rational and humane strategies are needed to simultaneously

o improve the health and survival of HIV-infected women,
o lift the burden of an impossible choice from mothers as they contemplate how best to feed their babies,
o prevent transmission of HIV to exposed infants, and
o protect food security for young children.

WABA calls on national and international leaders to close the gap between rich and poor countries regarding access to treatment, and to use current evidence to enact universal public health measures fostering overall child survival, both within and outside the context of HIV.

For more information, kindly contact:

Pamela Morrison IBCLC
Co-coordinator WABA Breastfeeding and HIV Task Force
Rustington, England