HO4.

8
AFASS Guidelines for HIV positive mothers to Assess Appropriateness of Replacement Feeding for their Infants
Will Replacement Feeding be ACCEPTABLE? The mother perceives no barrier to choosing the option for social and cultural reasons or for fear of stigma and discrimination The mother has adequate support to cope with family, community and social pressures e.g:

Will a mother who doesnt breastfeed be accepted in the community?

Will Replacement Feeding be FEASIBLE? The mother (and family) have adequate time, knowledge, skills, and other resources to prepare and feed the infant e.g:

Can a mother prepare fresh home formula every three hours, day and night?

Will Replacement Feeding be AFFORDABLE? The mother and family (with available community and/or health system support), can pay for the costs for the purchase/production, preparation, and use of the feeding option, including all ingredients, equipments, fuel, and clean water

e.g:

e.g:

Can the mother afford to pay 160 Birr the first month to feed the baby (or 240-320 Birr from the second month onwards)? Will the purchase of formula compromise the health & nutrition of other family members ?

Will Replacement Feeding be SUSTAINABLE? Replacement Feeding option must be practiced exclusively during six months, and day & night Supply and distribution of all ingredients is continuous, uninterrupted and dependable for as long as infants need it e.g: Can the mother /family buy formula (or milk) and equipments for six months and more ? e.g: Can the mother accept, even under family

pressure, NEVER to put the baby on the breast?

Will Replacement Feeding be SAFE? Replacement foods are correctly and hygienically stored prepared in nutritionally adequate quantities

general population

e.g: Does mother have easy access to clean water? e.g: Does mother have easy access to electricity or other source of energy? e.g: Does mother have access to a refrigerator? e.g: Does mother have clean hands and clean utensils for preparation (use a cup)

Replacement Feeding

HO4.9a

Preparation guide for home prepared replacement feedings for infants

Commercial formula Wash hands with soap and water. Clean all utensils, containers, and cups with soap and water. Read or have someone read instructions on the formula tin. Boil water for 10 minutes and let it cool. Boil as much water as you will need for the whole day and store in a clean covered container. Measure the amount of milk powder needed for one feed and mix it with the correct amount of boiled water. Prepare fresh commercial formula before each feed if refrigeration is not available Feed the infant by cup about 150 milliliters (ml) of correctly prepared formula per kg per day, divided into 68 feeds. The infant will have to learn to drink from a cup. Home-prepared formula Wash hands with soap and water. Clean all utensils, containers, and cups with soap and water. Boil water for 10 minutes and let it cool. Boil as much water as you will need for the whole day and store in a clean, covered container. Measure the amount of water and milk that you will need (see table 2). Measure the exact amount of sugar and mix it with the liquid (see table 2). Prepare formula before each feed if refrigeration is not available. Feed the infant by cup the appropriate amount based on the infants weight. The infant will have to learn to drink from a cup. Give the infant multivitamins specially formulated for the nonbreastfed child. The multivitamin can be in the form of liquid syrup (5 ml per day) or powder. The multivitamin can be mixed with the formula or given separately.

HO4.9b
Replacement Feeding: Recipes and amounts for replacement feedings needed at different ages
Number of Feedings and Daily Milk Requirements 8 feeds/day x 60 ml/feed Total: 480 ml/day 7 feeds/day x 90 ml/feed Total: 630 ml/day 6 feeds/day x 120 ml/feed Total: 720 ml/day 6 feeds/day x 120 ml/feed Total: Cow (fresh or UHT), goat, or camel (per feeding) Sheep and buffalo milk (per feeding) Evaporated milk (per feeding) Powdered full cream milk (per feeding) Commer-cial formula (per month)

Age (months)

0<1

40 ml milk +20 ml water + 4 grams (g) sugar (slightly less than 1 teaspoon) 60 ml milk +30 ml water + 6 g sugar (1 teaspoons)

30 ml milk + 30 ml water + 3 g sugar (slightly less than teaspoon) 45 ml milk + 45 ml water + 5 g sugar (1 teaspoon)

16 ml milk + 44 ml water + 4 g (level teaspoon) sugar 24 ml milk + 66 ml water + 6 g (1 teaspoons) sugar 32 ml milk + 88 ml water + 8 g (2 teaspoons sugar) 32 ml milk + 88 ml water + 8 g (2 level

5 g milk + 60 ml water + 4 g (level teaspoon) sugar 7.5 g milk + 90 ml water + 6 g (1 teaspoons) sugar

4 x 500-g tins

1<2

6 x 500-g tins

2<3

80 ml milk + 40 ml water + 8 g sugar (slightly more than 1 teaspoons)

60 ml milk + 60 ml water + 6 g (1 teaspoons)

10 g milk + 120 ml water + 8 g (two level tea-spoons) sugar

7 x 500-g tins

3<4

80 ml milk + 40 ml water + 8 g sugar (slightly more than 1 teaspoons)

60 ml milk + 60 ml water + 6 g (1 teaspoons)

10 g milk + 120 ml water + 8 g (two level tea-spoons) sugar

7 x 500-g tins

720ml/day

teaspoons) sugar 100 ml milk + 50 ml water + 10 g sugar 75 ml milk + 75 ml water + 8 g sugar (slightly more than 1 teaspoons) 40 ml milk + 110 ml water + 10 g (2 full teaspoons) sugar 12.5 g milk + 150 ml water + 10 g (two full tea-spoons) sugar 12.5 g milk + 150 ml water + 10 g (two full tea-spoons) sugar 8 x 500-g tins

4<5

6 feeds/day x 150 ml/feed Total: 900ml/day

5<6

6 feeds/day x 150 ml/feed Total: 900ml/day

100 ml milk + 50 ml water + 10 g sugar

75 ml milk + 75 ml water + 8 g sugar (slightly more than 1 teaspoons)

40 ml milk + 110 ml water + 10 g (2 full teaspoons) sugar

8 x 500-g tins

Source: HIV and Infant Feeding Protocol and Reference Guide for Counseling. WHO (forthcoming)

Advantages and Disadvantages of Different Infant Feeding Options under HIV and AIDS
OPTION: Exclusive Breastfeeding

HO4.10a

Advantages/Motivations: Breast milk is the perfect food for babies. It gives babies all of the nutrition and water that they need. They do not need any other liquid or food. Breast milk is free, it is always available and it does not need any special preparation. Exclusive breastfeeding protects infants from diseases, particularly diarrhea and pneumonia. Exclusive breastfeeding may also reduce the risk of HIV transmission. Many women breastfeed, and exclusive breastfeeding is recommended for HIV-negative women. People may be less likely to become suspicious about this feeding practice (compared with the other options). Exclusive breastfeeding delays ovulation, preventing sexually active women from becoming pregnant. Disadvantages/Constraints: The risk of HIV transmission exists for as long as the HIV-infected mother breastfeeds. This is because the infant continues to be exposed to HIV through breastfeeding. This risk of HIV transmission increases if the mother has a breast infection (e.g., mastitis) or cracked and bleeding nipples. Although exclusive breastfeeding is recommended, it is not the norm in most cultures. Family, friends, and neighbors may pressure mothers to give water, other liquids, or foods to the baby. Many mothers are concerned that they do not have enough milk to breastfeed exclusively Mothers who breastfeed exclusively must feed on demand, at least 810 times per day. It may be difficult for working mothers to feed on demand. Mothers who breastfeed have increased nutritional requirements. They require an additional 500-750 kcal/day to support exclusive breastfeeding in the first 6 months.

HO4.10b
OPTION: Wet-nursing
Advantages/Motivations: There is no risk of HIV transmission if the wet nurse is not HIVpositive. Disadvantages/Constraints: The wet nurse must be tested and confirmed to be HIV-negative. She must protect herself from HIV the entire time while breastfeeding. She must be available to breastfeed the baby frequently throughout the day and night, or she must also be able to express milk if she and the baby are separated. If the baby is infected with HIV, there is a very small chance that he/she could pass the virus to the wet nurse. People may ask mothers why someone else is breastfeeding her baby. The HIV-infected mother is at risk of becoming pregnant if sexually active.

HO4.10c
OPTION: Expressed and Heat-Treated Breast Milk
Advantages/Motivations: Heat-treating breast milk prevents HIV replication, reducing the risk of transmission. Breast milk is the perfect food for babies, and most nutrients remain in breast milk after heating. This method may be appropriate for breastfeeding mothers with sick and low-birth weight babies being fed in hospitals, mothers with breast infections, and during the transition from exclusive breastfeeding to replacement feeding. Other adult family members can help to feed the baby. Disadvantages/Constraints: Expressing and heating breast milk takes time and it must be done frequently. The baby will need to drink from a cup. Babies can learn how to do this even when they are very young, but it takes time. The breast milk needs to be stored in a cool place and used within an hour of heating. Fuel for heating the milk, and clean water and soap for washing all utensils are required. Some anti-infective (protective) cells in breast milk are destroyed with heating. This practice is only recommended for mothers with HIV. It is a new and unusual practice that may cause people to suspect HIV.

HO4.10d
OPTION: Replacement Feeding with Commercial Infant Formula
Advantages/Motivations: There is no risk of transmitting HIV through formula. Commercial infant formula is made especially for infants. Most of the nutrients that a baby needs have already been added to the formula. Other adult family members can help to feed the baby Disadvantages/Constraints: If the formula is not prepared correctly, an infant is more likely to get sick from diarrhea and pneumonia, and develop malnutrition. Formula is expensive. An infant needs a total of forty 500g tins (or forty-four 450g tins) for the first six months. This will cost between 1400 to 2600 Birr. A continuous/reliable supply of formula will be needed to prevent malnutrition. From 6-24 months, a suitable breast milk substitute (formula or animals milk) will still be required. This will represent a similar cost. Formula takes time to prepare, and it must be made fresh for each feed. The mother must stop breastfeeding completely, or the risk of giving HIV to her baby will be greater. The baby needs to drink from a cup. Babies can learn how to do this even when they are very young, but it takes time. Safe preparation requires clean water (boiled for 10 minutes), fuel, and soap for cleaning utensils. Formula does not contain antibodies, which protect infants from infection. If a mother does not breastfeed, it may arouse suspicion and even anger among family, neighbors, and friends. Formula feeding does not protect from pregnancy. Commercial infant formula requirements in first 6 months
Month First month Second month Third month Fourth month Fifth month Sixth month No. 500 g tins per month 4 tins 6 tins 7 tins 7 tins 8 tins 8 tins No. 450 g tins per month 5 tins 6 tins 8 tins 8 tins 8 tins 9 tins

HO4.10e
OPTION: Replacement Feeding with Home-prepared modified animal milk
Home-prepared formula can be made with fresh animal milks, with dried milk powder or with evaporated milk. Preparation of formula with any of these types of milk involves modification to make it suitable for infants from birth to 6 months. This modification includes dilution with boiled water in precise amounts to reduce solute concentration and the addition of sugar to increase energy density. The amount of dilution required varies for different animal milks. Dilution is not required for infants 6 months and older. Infants fed on home modified animal milk require additional micronutrient supplements because animals milks are relatively low in iron, zinc, vitamin A, vitamin C and folic acid. These milks are suitable for home-modified formula: Fresh cow, goat, sheep, buffalo milk Full-cream, dried milk powder Evaporated milk Ultra-heat treated milk (UHT) These milks/liquids are not suitable for home-modified formula Unmodified fresh animal milk Skimmed or low-fat milk powder Sweetened or condensed milk Thin cereal-based gruels Fruit juice Advantages/Motivations: There is no risk of transmitting HIV through home-prepared formula. Home prepared formula may be less expensive than commercial infant formula and it is easily available if the family has milk-producing animals. Home-prepared formula can be used on days when commercial infant formula supplies run out. Other adult family members can help to feed the baby. Disadvantages/Constraints: Animal milk is difficult for infants to digest.

Formulated for animals, these milks do not contain the nutrients that human babies need. Infants fed regularly on home-modified animal milk must also take a specially formulated multivitamin supplement (liquid or powder for infants) to prevent anemia and other forms of malnutrition. Fresh animal milk must be boiled. All animal milk must be diluted with boiled water. Sugar must also be added in correct amounts. Care must be taken to correctly mix these ingredients in order to prevent malnutrition and diarrhea. If the formula is not prepared correctly, an infant is more likely to get sick from diarrhea and pneumonia, and develop malnutrition. Formula takes time to prepare, and it must be made fresh each time you feed your baby. Infants require about 15 liters of milk per month for the first six months if fed on home-modified animal milk. Families will also need to buy sugar and multi-vitamin syrup or powder. This will cost approximately (local cost). The baby needs to drink from a cup. Babies can learn how to do this even when they are very young, but it takes time. Safe preparation requires clean water (boiled for 10 minutes), fuel, and soap for cleaning utensils. Formula does not contain antibodies, which protect infants from infection. If a mother does not breastfeed, it may arouse suspicion and even anger among family, neighbors, and friends. Home-prepared formula does not protect from pregnancy.

Early Breastfeeding Cessation

HO4.11

Advantages/Motivations: The infant is no longer exposed to HIV through breastfeeding. Disadvantages/Constraints: The infant may become malnourished if suitable breast milk substitutes are not available and provided appropriately. The infant may be at increased risk of diarrhea if breast milk substitutes are not prepared safely. If breastfeeding cessation is too rapid and infants are not prepared for the transition, they can become dehydrated, anxious, disoriented, and unhappy. They may cry excessively or refuse food, making the transition more difficult for themselves and their families. Infants should learn to cup feed before breastfeeding cessation. Cup feeding requires caregiver patience and time. The mothers breasts may become engorged and infected if milk is not expressed and discarded. The mother is at risk of becoming pregnant if sexually active. Early breastfeeding cessation is not recommended for infants who are already infected with HIV. Early Cessation: Breast milk substitute requirements for infants after 6 months of age Age 6-8 months 9-11 months 12-23 months Average amount of milk per day 600 ml 550 ml 500 ml

Mothers who choose to undertake early cessation of breastfeeding when their infant is about 6 months of age can either use infant formula or animal milk. Animal milks do not require dilution after 6 months. However, special preparation is still required for fresh and powdered milk: Fresh animals milk: Boil the milk to kill any bacteria. Powdered or evaporated milk: Add clean water according to the directions on the tin in order to make full strength milk. Processed/pasteurized or ultra-heat treated (UHT) milk: No preparation needed.