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

Editorial Note

In 2007, an estimated 13% of 159 diagnoses of HIV and acquired immunodeficiency syndrome (AIDS) among children aged <13 years were attributed to modes other than perinatal transmission, including hemophilia, blood transfusion, and risk factors not reported or identified.* In 2008, a case series of three pediatric HIV cases concluded that premastication was the likely mode of transmission for these children, a route not reported previously.¹ Bleeding gums at the time of premastication were reported in caregivers of two of the three children in the case series. The third caregiver could not recall her dental condition at the time of premastication. One of these transmissions was to a child whose mother was not HIV-infected. HIV transmission via premastication is presumed to require blood in the mouth of the caregiver. No evidence suggests that saliva alone can transmit HIV.

In addition to HIV, transmission of hepatitis B virus³ and group A streptococcus⁶ by premastication has been documented. Furthermore, premastication has been found to be associated with increased risk for infection with Helicobacter pylori,⁷Streptococcus mutans,² human herpesvirus 8,⁴ and Epstein Barr virus.⁵ Only one study has indicated that premastication can be associated with decreased risk for infection; that study involved respiratory syncytial virus in Alaska Native infants aged <6 months.⁹

The prevalence of premastication observed in this investigation is particularly important because most of the caregivers and premasticators were biologic mothers; thus, most caregivers were HIV-infected, posing a potential risk for HIV transmission to children in their care who are uninfected. Furthermore, the higher prevalence of premastication among black and younger caregivers suggests the need for targeted prevention messages for these populations.

The reasons given by caregivers for premastication might suggest that the practice is mostly situational or in response to immediate circumstances, as opposed to reasons that reflect an inability to provide baby food or formula. Therefore, prevention messages might be effective among this population, particularly those with situational reasons for premastication. Qualitative research on premastication might be helpful to explore the reasons for premastication and to determine helpful, realistic alternatives for HIV-infected caregivers.

The findings in this report are subject to at least three limitations. First, gathering HIV status information on caregivers was not possible because surveys were completed in a setting where caregivers were accompanied by their children and other family members, some of whom might have been unaware of their caregiver's HIV status. However, given that all caregivers were surveyed in pediatric HIV clinics and 81% of primary caregivers were biologic mothers, the majority of the caregivers surveyed likely were HIV-infected. Second, the surveyed caregivers were asked to recall behaviors that might have taken place several years before survey administration; therefore, these data might be affected by recall bias. Finally, this cross-sectional investigation included a convenience sample of caregivers of children seen in HIV clinics and is not generalizable to all HIV-infected caregivers.

Although research on the risk for HIV transmission via premastication is limited, CDC recommends that HIV-infected caregivers not premasticate food for HIV-uninfected children because of the possibility of transmitting HIV to the child. Public health officials and health-care providers should continue to educate the public about the risk for disease transmission, including HIV, via premastication.

References

1. Gaur AH, Dominguez KL, Kalish ML, et al. Practice of feeding premasticated food to infants: a potential risk factor for HIV transmission. Pediatrics 2009;124:658-66.
2. Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatr Dent 2007;29:16-22.
3. Huang MJ. An epidemiological study on prevalence and risk factors of hepatitis B virus (HBV) infection in preschool children [Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi 1990;11:129-32.
4. Mbulaiteye SM, Pfeiffer RM, Whitby D, Brubaker GR, Shao J, Biggar RJ. Human herpesvirus 8 infection within families in rural Tanzania. J Infect Dis 2003;187:1780-5.
5. Mbulaiteye SM, Walters M, Engels EA, et al. High levels of Epstein-Barr virus DNA in saliva and peripheral blood from Ugandan mother-child pairs. J Infect Dis 2006;193:422-6.
6. Steinkuller JS, Chan K, Rinehouse SE. Prechewing of food by adults and streptococcal pharyngitis in infants. J Pediatr 1992;120(4 Pt 1):563-4.
7. Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991;13:42-59.
8. Fein SB, Labiner-Wolfe J, Scanlon KS, Grummer-Strawn LM. Selected complementary feeding practices and their association with maternal education. Pediatrics 2008;122(Suppl 2):S91-7.
9. Bulkow LR, Singleton RJ, Karron RA, Harrison LH. Risk factors for severe respiratory syncytial virus infection among Alaska native children. Pediatrics 2002;109:210-6.

* Additional information available at www.cdc.gov/hiv/surveillance/resources/reports/2008report/index.htm.