Premastication of Food by Caregivers of HIV-Exposed Children -- Nine U.S. Sites, 2009-2010

March 11, 2011

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Premastication (i.e., chewing foods or medicines before feeding to a child) was reported recently as a route of human immunodeficiency (HIV) transmission through blood in saliva1 and has been associated with transmission of other pathogens.2-7 Approximately 14% of caregivers in the United States report premastication;8 however, the frequency of this behavior among HIV-infected caregivers is unknown. To assess the prevalence of premastication among caregivers of children being treated in pediatric HIV clinics, which include perinatally HIV-exposed children (i.e., HIV-uninfected and HIV-infected children born to an HIV-infected mother), CDC conducted a cross-sectional survey at nine such clinics in the United States during December 2009 - February 2010. This report describes the results of that survey, which indicated that among primary caregivers of children aged ≥6 months, 48 (31%) of 154 reported the children received premasticated food from themselves or someone else. Approximately 37% of black caregivers reported premastication, compared with 20% of non-black caregivers (prevalence ratio [PR] = 1.8). Premastication decreased with caregiver age and was used to feed children aged 1-36 months. Public health officials and health-care providers should educate the public about the risk for disease transmission via premastication and advise HIV-infected caregivers against the practice.

Pediatric HIV clinics with which the CDC had collaborated previously in premastication-related or longitudinal, HIV-related epidemiologic studies participated in this investigation. These clinics were located in Atlanta, Georgia; Dallas, Texas; Houston, Texas; Memphis, Tennessee; Miami, Florida; New Orleans, Louisiana; Newark, New Jersey; San Juan, Puerto Rico; and the District of Columbia. A 10-minute, self-administered paper questionnaire was distributed to primary caregivers during their child's clinic visit. A primary caregiver was defined as the person responsible for feeding, clothing, and housing the child. One survey per child with an appointment was allowed; therefore, multiple interviews were possible if a caregiver had multiple children with appointments. After completion of the survey, caregivers were provided written information and counseled about the risk for disease transmission through premastication. Of 203 primary caregivers approached, 192 (95%) were surveyed (11 declined participation).


Of the 192 primary caregivers surveyed, the majority were biologic mothers of the children (81%) and U.S.-born (86%). Approximately 66% of caregivers were non-Hispanic black, 24% were Hispanic, and 7% were non-Hispanic white. The median age was 31 years for primary caregivers (range: 15-77 years) and 2 years for children (range: <1-18 years). Approximately 30% of caregivers had less than a high school education, and 49% had an annual household income of less than $12,000.

Given the decreased likelihood that children are fed solid foods during the first months of life, CDC limited its analysis to caregivers of children who were aged ≥6 months at the time of investigation (155 [81%] of 192). Among primary caregivers of these children, 44 (29%) of 153 reported ever premasticating food for the child. Fourteen (10%) of 140 primary caregivers reported that someone else had given premasticated food to the child. Overall, 48 (31%) of 154 primary caregivers stated that they or someone else had premasticated food for the child, with biologic mothers representing 79% of premasticators. Black caregivers more frequently reported ever premasticating food, compared with non-blacks (37% versus 20%, respectively; PR = 1.8) (Table 1). Premastication decreased with increasing caregiver age at interview. Caregivers aged ≤19 years were significantly more likely to premasticate than those aged ≥40 years (44% versus 13%, respectively; PR = 3.5), as were those aged 20-29 years (38% versus 13%, respectively; PR = 2.9) and those aged 30-39 years (36% versus 13%, respectively; PR = 2.8). Similar prevalences of premastication were found regardless of the sex of the child and the primary caregiver's country of origin, education level, and income (Table 1).

Primary caregivers started premastication of food for children as young as age 1 month (median age: 7 months) and stopped premastication as late as age 36 months (median age: 13 months). Among 38 premasticating primary caregivers who described frequency of the behavior, 15 (39%) reported premasticating 1-3 days in a typical week, 14 (36%) reported 4 or more days, and nine (24%) reported less than once a week. The most commonly reported reasons for premastication, reported from a predetermined list, were "child wanting some of the caregiver's food" (64%), "caregiver not wanting the child to choke" (62%), and "prechewing is done in my family" (31%) (Table 2). Meat and fish (80%) and fruit (39%) were the most commonly reported food types premasticated by caregivers.

Reported by: N. Rakhmanina, M.D., Children's National Medical Center; S. Hader, M.D., A. Denson, Dept of Health, Washington, DC; A. Gaur, M.D., St. Jude Children's Research Hospital, Memphis, Tennessee; C. Mitchell, M.D., Miller School of Medicine, Univ of Miami; S. Henderson, M.D., Emory Univ, Atlanta, Georgia; M. Paul, M.D., Baylor College of Medicine, Texas Children's Hospital, Houston; T. Barton, M.D., Southwestern Medical Center, Dallas, Texas; M. Herbert-Grant, M.D., University Hospital, New Jersey Medical School; E. Perez, Univ of Puerto Rico; J. Malachowski, Tulane Univ School of Public Health, New Orleans, Louisiana; K. Dominguez, M.D., S. Danner, S. Nesheim, M.D., Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; W. Ivy, Ph.D., D. Iuliano, Ph.D., EIS officers, CDC.

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This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication Morbidity and Mortality Weekly Report. Visit the CDC's website to find out more about their activities, publications and services.

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