Introduction The Breastfeeding Promotion Network of India (BPNI) had issued a Position Statement earlier in 19991 and this is now revised and updated with a view that it will be further updated from time to time with the new evidence. BPNI and International Baby Food Action Network (IBFAN) work on protection, promotion & support of breastfeeding in India and globally. This document aims to provide some policy recommendations on this issue to the policy makers, program managers, NGOs and International organizations working on mother and child health. Breastfeeding and its role Breastfeeding is the optimal way to feed an infant. It greatly improves quality of life by providing unique nutritional, immunological, economic, ecological, psychological and child spacing benefits. Breastfeeding also enhances maternal health. Breastfeeding saves lives. Infant mortality continues to be very high in the region and artificial feeding contributes to a major part of this. The underweight (weight for age) children <5 yrs in South Asia is about 40% which was 58% in 1975.2 The fall in percentage prevalence of protein- energy malnutrition has not been as rapid as the rise in population. Malnutrition is rampant among infants and this can be prevented to a significant extent by breastfeeding. Indeed, breastfeeding is a right of the mother and child and society must take all necessary steps to protect, support and fulfil that right. HIV transmission during breastfeeding and infant feeding HIV has been isolated in breastmilk. Mother to child transmission (MTCT) via breastfeeding to uninfected infants born to women with HIV infection is estimated to occur in 10% to 20% cases due to partial breastfeeding. This risk is higher among women who become infected while breastfeeding and among those suffering from AIDS symptoms. There is heightened risk of transmission during the early months. Mothers, health workers and organizations such as IBFAN groups are thus faced with a dilemma on advising infant feeding options i.e. exclusive breastfeeding or artificial feeding or mixed feeding. It is extremely difficult to know under what situations complete artificial feeding from birth is the safest alternative. Mixed feeding is likely to lead to higher levels of MTCT than either complete artificial feeding or exclusive breastfeeding Also, as most HIV-infected pregnant women may not know of their HIV status, adoption of exclusive breastfeeding for about six months by all mothers may lead to an overall reduction of MTCT throughout the region. This would have a wide range of positive effects in improving infant nutrition and reducing other infections as well. Recommendations 1. The general principle "irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported" should be followed. 2. Priority should be given to policies and programmes, which aim to prevent women of reproductive age particularly adolescents and their partners from becoming infected with HIV in the first place. 3. Voluntary and confidential counselling and HIV testing should be made available for women of childbearing age and their partners. Investments in training of health workers about HIV and testing HIV infection should be made. 4. Women should be "empowered to make fully informed decisions"4 about infant feeding and supported in these decisions after having been properly informed. 5. For those women who are aware that they are HIV-positive, information should include the benefits of breastfeeding especially 'exclusive' and risks of artificial feeding and the additional risk of MTCT via breastfeeding, especially mixed feeding. This should be done in a supportive environment, minimizing any possible discrimination and stigmatization. 6. Training of health workers in breastfeeding and lactation management is very essential and substantial investments be made in this area. 7. Counselling about artificial feeding should be provided only to individual women who are tested positive for HIV or present with clear symptoms of AIDS, and have decided to artificial feed. 8. Women should be informed about alternative methods of providing breastmilk to their infants, including: (a) Pretoria pasteurization of expressed breastmilk (placing it in a jar in a pan of boiling hot water),5 (b) wet nursing, preferably by a person tested to be HIV-negative, and (c) 3-6 months of exclusive breastfeeding followed by a rapid transition to alternative feeding modes (6 months of exclusive breastfeeding will reduce or eliminate the need to use more expensive artificial feeding with home-made or commercial infant formulas). Cup feeding is preferable for milk and other liquid feeds. International Code of Marketing of Breast-Milk Substitutes and subsequent World Health Assembly (WHA) Resolutions 9. Improper implementation of guidelines regarding the reduction of MTCT via breastfeeding could have a severely harmful effect on the society as a whole. Thus, emphasis must be placed on complete adherence to the International Code of Marketing of Breast-milk Substitutes and relevant WHA resolutions, including a ban on donations or low cost supplies of commercial infant foods within any part of the health care system. 10. The commercial infant food industry has no role other than the one they had before the HIV-epidemic started: manufacturing and making available through normal marketing channels safe products that meet an existing demand, as well as scientifically accurate information about these products to health workers on request. Any practice aimed at artificially increasing that demand, including offering inducements to the health professionals, lobbying, and other interference in national, regional and international infant feeding policy making, is ethically abhorrent and should continue to be counteracted by all organizations concerned with maternal and infant health. The industry should follow the International Code of Marketing of Breastmilk Substitutes (1981) and World Health Assembly resolutions (WHA 45.34,1992; WHA 47.5,1994). Research 11. Additional independent research is urgently needed to fill gaps in existing knowledge. Priority should go to prospective research on the extent to which HIV transmission occurs when exclusive breastfeeding from birth up to about six months is practiced, as well as the extent of MTCT after this age when mothers choose to continue breastfeeding while providing adequate complementary feeding. Research should also address other health outcomes in infants of HIV-infected mothers provided with different feeding regimes and how to improve nutritional status of HIV infected mother & infected children. 12. Teams researching such issues should include expertise not only in virology and research design, but also in breastfeeding management. Those who have no commercial interest in the outcome should finance research on infant feeding in a transparent and independent manner. Financing of both research and program activity should not create conflicts of interest. References 1. Position Statement on HIV and HIV and Infant Feeding. BPNI New Delhi. January 1999. 2. Protein Energy Nutrition. Nutrition Profile in South-East Asia Region, New Delhi World Health Organization, Regional Office for South-East Asia, New Delhi. 2000. Pp 8-11. 3. Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet. 1999 Aug 7;354(9177):471-6. 4. HIV and Infant Feeding. A Policy Statement Developed Collaboratively by UNAIDS, WHO and UNICEF. May 1997. 5. BS Jeffery and KG Mercer. Pretoria pasteurisation: a potential method for the reduction of postnatal mother to child transmission of the human immunodeficiency virus. J Trop Pediatrics 46: 219-223, 2000. During the International Baby Food Action Network (IBFAN) South Asia's Regional Training Seminar, "Healthy Futures: Challenges for the 3rd Millennium", 14-17th November, 2000 in Parwanoo, India, 40 participants including nutrition and health professionals, governments and NGOs and researchers from seven countries in the South Asia Region and three other southeast Asian countries re-evaluated the situation on HIV & breastfeeding in the light of currently available information and this statement and recommendations were adopted. Breastfeeding
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