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Pediatrics Association Recommends Bottle Feeding for Babies of HIV+ Mothers

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HIV positive women in high-income countries where clean water and safe baby formula are widely available should avoid breast-feeding -- regardless of antiretroviral therapy (ART) use or low viral load -- in order to minimize the risk of transmitting the virus to their infants, according to a new policy statement from the American Academy of Pediatrics.

Due to limited availability of clean water and suitable baby formula in resource-limited countries, as well as the competing risk of inadequate nutrition, the World Health Organization recommends that HIV positive mothers should breast-feed exclusively for 6 months if replacement feeding is not "acceptable, feasible, affordable, sustainable, and safe."

In contrast, public health experts have consistently advised women with HIV in the U.S. and other high-income countries not to breast-feed their babies, since high-quality formula is readily available. But the latest U.S. HIV treatment guidelines recommend that all pregnant women should start combination ART, and studies have shown that effective antiretroviral treatment dramatically reduces the risk of transmission, leading some to suggest that breastfeeding should be an option in this setting.

A recent policy statement from the American Academy of Pediatrics (AAP), published in the January 28, 2013, advance edition of the journal Pediatrics, continues to recommend against breast-feeding in the U.S., however.

"Because the only intervention to completely prevent HIV transmission via human milk is not to breast-feed, in the United States, where clean water and affordable replacement feeding are available, the American Academy of Pediatrics recommends that HIV-infected mothers not breast-feed their infants, regardless of maternal viral load and antiretroviral therapy," the group concluded.

The organization also offered a list of 11 guidelines, summarized below:

1. Women and their physicians need to be aware of the potential risk of HIV transmission to infants during pregnancy, during labor and delivery, and from breast-feeding.

2. Documented routine, opt-out HIV antibody testing should be performed for all women seeking prenatal care in the United States.

3. For women in labor with undocumented HIV status during the current pregnancy, maternal HIV antibody testing with opt-out consent by using a rapid HIV test is recommended.

4. In the rare situation in which rapid HIV testing during labor is not immediately available, women with unknown HIV status should be counseled...regarding the potential high risk of HIV transmission through human milk should she be infected, and that an HIV test would be advised before initiation of breastfeeding.

5. In the United States, HIV-infected women should be counseled not to breastfeed or to provide their milk for the nutrition of their own or other infants, regardless of antiretroviral drug use or viral load.

6. Women who are HIV seronegative should be strongly encouraged to exclusively breast-feed their infants.

7. Women who are HIV seronegative but who are at particularly high risk of seroconversion...should have repeat HIV testing and be provided education about HIV and the risk of transmission through human milk and should be provided an individualized recommendation concerning the appropriateness of breast-feeding.

8. In postpartum lactating women with suspected acute HIV infection, breast-feeding should be stopped until HIV infection is confirmed or ruled out.

9. Neonatal intensive care units (NICUs) should develop polices for use of expressed milk for nutrition of neonates....gloves should be worn by health care workers in situations in which exposure to human milk might be frequent or prolonged.

10. Human milk banks should follow guidelines developed by the U.S. Public Health Service, which include donor screening for HIV infection and assessing risk factors that predispose to infection, as well as pasteurization of all human milk specimens.

11. Physicians should routinely in- quire about pre-mastication [chewing food for infants] and pre-warming feeding practices and instruct HIV-infected caregivers on safer feeding options.

1/29/13

Reference

American Academy of Pediatrics. Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States (policy statement). Pediatrics. January 28, 2013 (Epub ahead of print).