ABSTRACT
A prospective study of seventy four mothers was designed to
assess impact of HIV infection on infant feeding practices and nutritional
status of children born to HIV positive mothers’ aged zero to six
months. The study carried out in Ahmadu Bello University Teaching
Hospital-Zaria, from birth to six months, with the objectives of assessing the
impact of HIV infection on infant feeding practice among HIV infected mothers,
assessing the effect of feeding practices on the nutritional status of infants
of HIV infected mothers, and assessing the impact of education, on infant
feeding practicing among HIV positive mothers. Data collection involved
administration of semi-structured questionnaire, taking anthropometric
measurement of their babies and their folders were used to collect more
information that could not be obtained from the caregivers directly such as
CD4+ count. Data was analyzed using WHO Anthro. Maternal knowledge on Mother to
Child Transmission of HIV was high and is reflected in maternal choice of infant
feeding practice where 95.95% practiced exclusive breastfeeding. On the other
hand, level of formal education attained has no association on choice of infant
feeding practice while exposure to other information received through health
talks and or counselling from health workers or media influenced their choices.
Despite high level of maternal knowledge on Prevention of Mother to Child
Transmission of HIV, few respondents practiced mixed infant feeding before 6
months. The exposed children were moderately undernourished because, in all the
indexes; none was below -2 Z-score, with values revolving between -1 Z-score
and -2 Z-scores. In conclusion, the choice of infant feeding practice is
significantly associated (p < 0.05) with level of maternal knowledge of PMTCT
of HIV as seen in the Chi-square value calculated compared to the
tabulated value, while commonly used infant feeding option among the mothers is
exclusive breast
feeding.
CHAPTER
ONE
1.0 INTRODUCTION
1.1 Research
Background
The Global Strategy for Infant and Young Child Feeding
(IYCF), adopted by the World Health Organization (WHO) and United Nations
Children Fund (UNICEF), states that the optimal feeding pattern for overall
child survival is exclusive breastfeeding for the first six months, and
continued breastfeeding for up to two years and beyond, with complementary
feeding from age six months, together with related maternal nutrition and
support (WHO, 2010). The Global Strategy contains specific recommendations for
children in exceptionally difficult circumstances, including those born to
HIV-positive women. Action to reduce child morbidity and mortality and to
promote family health has greatly improved child health (Walker et al.,
2002, Black et al., 2003).
Promotion of breast-feeding has contributed significantly in
that it provides optimum nutrition, protects against common child-hood
infections, reduces mortality significantly, and has child-spacing effects (Nicollet
al., 2000; WHO Collaborative Study Team, 2000). Nearly all infants in
developing countries are initially breastfed, and most continue until at least
six months of age but often into the second year (Nicollet al., 2000,
WHO Collaborative Study Team, 2000). Continued breastfeeding (beyond six
months) is common in sub-Saharan Africa and Asia, but much less so elsewhere.
Up to 94% of infants in the world are estimated to be ever breastfed, 79% to
continue at one year, and 52% at two years, with an estimated median duration
of breast feeding of 21 months (WHO, 2010). Overall, an estimated 41% of
infants less than four months of age and 25% under six months are exclusively
breastfed; in sub-Saharan Africa 23%of infants less than six months of age are
exclusively breastfed (WHO, Global Databank on Breastfeeding and Complementary Feeding, 2003a).In 2001 the World Health
Assembly endorsed the recommendation that infants should be exclusively
breastfed for the first six months of life to achieve optimal growth,
development and health. After six months, they should receive nutritionally
adequate and safe complementary foods while breastfeeding continues up to 24
months or beyond. This recommendation takes into account the considerable
benefits of breast-feeding, as well as the adverse effects of artificial
feeding at an early age. Exclusive breastfeeding is the best form of feeding
for the infant during the first six months of life (WHO, 2001a). Also, it helps
the mother space her pregnancies. A woman who exclusively breastfeeds during
the first six months and who has not resumed menstruation has a less than 2%
risk of becoming pregnant (WHO, 2000b). Exclusive breastfeeding on a population
basis has been shown to be feasible with adequate support and training of
health-care professionals (Kramer et al., 2001; Bhandari et
al., 2003).
Infant and young child feeding in the context of Human
Immunodeficiency Virus (HIV) poses significant challenges due to the risk of
transmission of the virus via breastfeeding. Prior to the 2010 guidelines on HIV and infant feeding, avoidance
or early cessation of breastfeeding seemed logical or appropriate (United
Nations, 2014). However, the repercussions for the health and survival of the
infants were serious, with studies howling much higher mortality rates due to
diarrhoea, malnutrition and other diseases in non-breastfed children. The 2010
recommendations were based on evidence of positive outcomes for HIV-free
survival through provision of ARVs to breastfed HIV-exposed infants. Thus the
focus is now firmly on ensuring HIV-free survival, not just on preventing
transmission. The WHO, (2010) guidelines provide a much clearer pathway towards
this goal. Breastfeeding carries significant health benefits for infants and
young children and is an essential child survival intervention. Without
intervention, about 35% of HIV-positive pregnant women will pass on the infection to their
babies during pregnancy, delivery and post-natally through breastfeeding.
Without preventive interventions, about 10-20 per cent of infants born to
infected mothers will contract the virus through breast milk if breastfed for
two years. The risk of postnatal HIV transmission after 6 weeks of age is
estimated at around 1% per month of breastfeeding (WHO, 2006).Several other
factors affect the risk of transmission, including the ―viral load‖ or amount
of virus in the mother‘s body (highest risk after infection and when AIDS
develops; a very sick mother is eight times more likely to transmit HIV to her
infant than a healthy mother), the duration of breastfeeding (the longer the
period, the greater the risk, as transmission is cumulative), and the condition
of the breasts (whether there are sores around the nipples e t c.) (WHO, 2010).
Method of infant feeding is clearly associated with the risk
of transmission through breast milk. Exclusive breastfeeding for the first six
months is associated with a 3-4 fold lower risk of HIV transmission as compared
to mixed feeding (mixed feeding means the infant receives both breastmilk and
any other food or liquid including water, non-human milk and formula before 6
months of age)(WHO, 2010). One study found that only about 4% of exclusively
breastfed infants became infected with HIV between 6 weeks and 6 months, even
in the absence of ARVs (WHO, 2007). It is believed that mixed feeding in the
first six months carries a greater risk of transmission because the other
liquids and foods given to the baby alongside the breastmilk can damage the
already delicate and permeable gut wall of the small infant and allow the virus
to be transmitted more easily. Mixed feeding also pose the same risks of
contamination and diarrhea as artificial feeding; diminishing the chances of
survival (WHO, 2010).Unfortunately mixed feeding is still the norm for many
infants less than six months old in many countries with high HIV prevalence.
Exclusive breastfeeding rates among children less than six
months of age in two-thirds of developing countries with trend data have
increased between 1998 and 2008, but are still quite low at 33% in sub-Saharan
Africa (WHO, 2010). Thus HIV transmission through breastfeeding can be reduced
if HIV-positive women breastfeed exclusively for six months rather than
practising mixed feeding. Public health programs for protection, promotion and
support of breastfeeding can have major benefits for HIV-positive women and
their children, as well as for the population in general. With the new
recommendations, it is postulated that an HIV-infected woman who takes ARVs and
mix-feeds may still have a higher rate of transmission than a mother who
exclusively breastfeeds and takes ARVs: the transmission risk is shifted
downwards for all breastfeeding mothers but the pattern of higher risk remains
for the mixed-fed infants (WHO, 2010). Therefore continued emphasis needs to be
placed on discouraging mixed feeding in the first six months. The risk of
HIV-infection has to be compared with the risk of morbidity and mortality due to
not breastfeeding. In general, babies who do not breastfeed are more than 14
times more likely to die from diarrhoea or respiratory infections than babies
who are exclusively breastfed in the first six months (Bhandari et al.,
2003).
The benefits of breastfeeding have been well described in
the medical literature (Cesar et al., 1999; WHO, 2000a; Kramer et al.,
2001). These benefits – including providing optimal nutrition, preventing
common childhood illnesses and improving child spacing – are of particular
importance in resource-poor countries such as in sub-Saharan Africa. For this
reason, the possibility of HIV transmission through breastmilk poses a dilemma,
particularly in conditions where breastfeeding is a strong cultural norm, and
where large numbers of women are infected with HIV.
It is estimated that 15% of infants born to HIV-infected
women acquire the infection through breast-feeding (De Cock et al.,
2000). Risk factors for Mother-To-Child Transmission of HIV (MTCT) through breastfeeding
include: the duration of breast-feeding; maternal characteristics such as
younger maternal age and higher parity; low CD4+ count; high peripheral blood
and maternal milk viral load; mastitis and breast abscess; infant
characteristics such as oral candidiasis; and possibly the pattern and duration
of breastfeeding (de Martino et al., 1992; Ekpini et al., 1997;
Miotti et al., 1999; Semba et al., 1999; Coutsoudis and Rollins,
2003).
Research has provided some evidence about the risk of HIV
transmission according to the pattern of breastfeeding, and has provided
additional incentive for consistent and strict definitions of infant feeding
patterns (Greiner, 2002). The possible association between infant feeding
patterns among infants who are breastfed by infected mothers and the risk of
MTCT was first evaluated in a prospective study conducted in South Africa
(Coutsoudis et al., 2001). In the study, it was found that, by 15 months
of age, the cumulative probability of HIV infection was lower among infants who
were exclusively breastfed compared with those who were mixed fed (i.e. those
who received other foods and liquids in addition to breast milk). These
findings were later confirmed in Zimbabwe (Iliff et al., 2005)
HIV can be transmitted through breast milk at any point
during lactation, and thus the rate of infection in breastfed infants increases
with duration of breastfeeding. The persistence of maternal antibodies and the
presence of a ―window period‖ during which infection is undetectable by current
technology makes it difficult to determine whether an infant has been infected
during delivery (intrapartum) or – through breastfeeding – immediately after
birth. There is too little information to estimate the exact association
between duration of breastfeeding and risk of transmission. There is strong
evidence, however, that the longer the duration of breastfeeding the greater the risk of transmission – in
other words, the risk is cumulative (Leroy et al., 1998; Miotti et al.,
1999; Leroy et al., 2002; Read, 2003).
It is difficult to draw any conclusions about the relative
risk of transmission by colostrum and mature breast milk (Van de Perre et al.,
1993; Ruff et al., 1994; Nduati et al., 1995; Lewis et al.,
1998). First, colostrum and mature breast milk contain different types of cells
and different levels of immune modulating components (e.g., vitamin A,
immunoglobulins and lactoferrin). Second, the infant ingests much less
colostrum than mature breast milk. Third, the infant‘s immune system is less
well developed in the first few days of lactation than later, and younger
infants have an increased blood concentration of maternal antibodies. There is
no evidence to suggest that avoidance of colostrum would reduce the risk of
breastfeeding transmission to the infant ( Lewis et al., 1998).
Statistical modelling, with data from studies in which
breastfeeding was of limited duration, has suggested that the highest-risk
period for transmission is the first several weeks of life, and that
infectivity may vary in populations at different stages of the epidemic (Dunn et
al., 1998). The randomized trial in Nairobi, Kenya, comparing breast milk
with formula, suggested that 10% of the cumulative difference in infection rates
between infants in the breastfed and formula-fed arms had occurred by six weeks
of age, compared with the total cumulative difference of 16%. Also, 75% of all
breastfeeding transmission had occurred by six months of age (Nduati et al.,
2000).
Given the risk of HIV transmission associated with
breastfeeding, it would appear that the simplest and most straightforward
approach to prevention is to avoid breastfeeding when mothers are infected.
This is the recommendation in many parts of the developed world (American Academy of Paediatrics, Committee on Paediatric
AIDS, 1995). However, a similar recommendation would be difficult for
sub-Saharan Africa. First, most women in sub-Saharan Africa breastfeed their
infants from birth, and for well over two years. Second, in most parts of
Africa, replacement feeding is often associated with an increased risk of
morbidity and mortality, in part because poverty constrains the provision of
appropriate and safe replacement feeds for children (WHO, 2000b).
WHO guidelines for infant feeding in the context of HIV
recommend the avoidance of all breasts feeding in conditions where foods that
can replace breastmilk are ‗Acceptable, Feasible, Affordable, Sustainable and
Safe‘. These conditions are often referred to as the AFASS conditions for
replacement feeding. Otherwise, the WHO recommends exclusive breast-feeding up
to 6 months of age. Thereafter, because the risk of HIV transmission may
outweigh the protective benefits of breast milk, mothers should quicken transition
from breastfeeding to exclusive replacement feeding (ERF) (Ross and Labbok,
2004). In the HIV and infant feeding literature, this is commonly referred to
as ‗rapid weaning‘. Rapid weaning poses an additional problem for HIV-infected
mothers. Even before the advent of the HIV pandemic, the risk of transition
from breast milk to replacement feeds had been widely recognized. Up to 6
months of age, breastfeeding provides considerable benefits for infant health;
however, thereafter, breastmilk is an inadequate source of nutrition, and it
needs to be supplemented with other foods and liquids (Ross and Labbok, 2004).
With
the introduction of weaning foods, infants experience an increased risk of
morbidity, particularly when the transition is not well managed, putting them
at a high risk of malnutrition and/or infection. This is commonly referred to
as the ‗weanling dilemma‘. Diarrhoea rates have been shown to be highest
between the ages of 6 and 12 months, coinciding with the introduction 24 of weaning foods (Pelto et al., 2003). There have
been relatively few studies investigating the issue of rapid weaning for
HIV-infected mothers. Anecdotal reports suggest that rapid weaning is
associated with increased mortality, particularly for mothers who do not have
adequate weaning foods. However, to the best of my knowledge, there have been
no published studies investigating the problem of rapid weaning for
HIV-infected mothers.
1.2 Statement of
Research Problem
Paediatric AIDS is poised to become a major public health
problem in Nigeria. Nutritional status of mother is an important indicator
which determines the fetal malnutrition, newborn morbidity and mortality in HIV
infection.
Forty two countries in the developing world carry 90% of
child global deaths, and 25% of those deaths could be reduced through simple
and preventive nutritional interventions, such as, exclusive breastfeeding,
appropriate complementary feedings, and vitamin A and zinc supplementation. (Bhandari
et al., 2003).
Various ongoing or planned trials and studies concern either
mode of infant feeding (exclusive or mixed) or antiretroviral therapy to either
the mother or the infant over the breastfeeding period; but the main problem
is, whether breastfeeding by HIV-infected mothers can be made safer as to
transmission risk, given the possible adverse effects of refraining from
breastfeeding (Ross and Labbok, 2004).
Nutritional
impairment is a big problem in our society today, with all the Government has
initiated, i .e. different nutritional strategies at both community and health
facility levels. At the community level, an outreach program of vitamin A
supplementation for 6 to 9 months-old children was implemented. Further, IYCF
strategies and policies were adjusted to guide health 25 workers and nutritionists practicing at central and local
levels in counseling HIV-positive mothers [WHO, 2009]; but still there are no
positive results.
Little is known about infant feeding practices and their
relationship to the nutritional status among HIV exposed infants. Still less
knowledge on this topic has been generated from longitudinal data.
1.3 Justification
for Research
i.
Although some data exist about the
deleterious effect of HIV infection on the growth of infected children, no data
exists about the importance of nutritional assessment of newborn of HIV
infected mothers.
ii. Prevention
of HIV transmission during breast-feeding should be considered in a broad
context that takes into account the need to promote breastfeeding of infants
and young children in the general population.
In view of the
above statements, there is a need to understand and come up with effective
strategies of infant feeding among HIV positive mothers.
1.4 Aim and
Objectives
The aim of this
study is to assess the Impact of HIV on infant feeding practices and
nutritional status of HIV-exposed infants (0-6 months) of HIV positive mothers.
1.4.2 Specific
Objectives
i.
To assess the impact of the HIV
infection on infant feeding practice among HIV infected mothers.
ii.
To assess the effect of feeding
practices on the nutritional status of the infants of HIV infected mothers
using anthropometry parameters.
iii.
To assess the impact of education,
on the infant feeding practiced, among HIV positive mothers.
1.4.3 Research
Hypothesis
Null
Hypothesis (Ho): There is no association between educational status
and breast feeding pattern.
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