January 31, 2013
Mothers in the U.S. living with HIV should avoid breastfeeding their infants, according to a new policy statement released by the American Academy of Pediatrics (AAP). Bottle feeding using infant formula is recommended, regardless of the woman's antiretroviral drug use or viral load.
This recommendation breaks from the current AAP stance in favor of breastfeeding for HIV-negative women. It also differs from the World Health Organization (WHO) guideline that supports breastfeeding for infants born to HIV-positive mothers in resource-limited settings, where clean water and infant formula is not as accessible. In these settings, infectious disease and malnutrition are major causes of infant deaths. Therefore, the WHO recommends exclusive breastfeeding for the first six months, followed by breastfeeding plus complementary foods from six to 12 months, combined with antiretroviral prophylaxis for mother or infant to reduce the risk of HIV transmission.
Without prophylaxis, the risk of infection for the baby is around 1% per week in the first 4 to 6 weeks of life, then about 0.2% per week for the duration of breastfeeding, translating to a cumulative transmission risk of 14% in one study.
With 6 months of antiretroviral prophylaxis, the risk dropped to 1% to 5% in studies of African mothers.
Although a low risk, "transmission can occur despite undetectable maternal plasma RNA concentrations," noted Lynne Mofenson, M.D., of the National Institute of Child Health and Human Development in Rockville, Md., and colleagues in the AAP statement.
Therefore, in the U.S., where clean water and infant formula are readily available, the AAP recommends bottle feeding for all infants to HIV-positive mothers, stating, "The risks of infectious diseases and malnutrition for infants who are not breastfed are outweighed by the risks of HIV transmission through human milk and where alternatives to breastfeeding are available."
If mothers can't afford infant formula, pediatricians should advise them on how to get appropriate financial support, such as applying to the Special Supplemental Nutrition Program for Women, Infants and Children, the policy statement says.
The statement also noted that flash-heating breast milk (heating milk in a water bath to 100°C and removing it when water reaches a rolling boil, then allowing it to cool), which pasteurizes the milk, does not completely destroy the HIV in that milk.
In addition, the group warned against feeding infants premasticated (or prechewed) food, since previous evidence suggested that this was a route of HIV transmission in some infants living with HIV. Therefore, HIV care providers are advised to consult HIV-positive mothers about safer feeding options.
While these recommendations are strongly urged, if mothers living with HIV (who are on treatment and virally suppressed) choose to breastfeed despite counseling, this would not constitute grounds for a referral to child protective services agencies, the statement says.
"Because the only intervention to completely prevent HIV transmission via human milk is not to breastfeed, in the United States, where clean water and affordable infant formula are available, the AAP recommends that HIV-infected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy," the group concluded.
These recommendations are part of 11 in total that the AAP released for HIV-positive women who are pregnant or are mothers to newborns, as well as their physicians.
Warren Tong is the research editor for TheBody.com and TheBodyPRO.com.
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