TOPIC 6. FEEDING BABIES AGED 0-6 MONTHS

NUTRITION NOTES

How you help a mother to feed her young baby depends on whether the mother is HIV- (negative), of unknown HIV status or HIV+ (positive). Much research is presently being done on the feeding of babies whose mothers are HIV+. The advice given in this topic is what nutritionists currently (in 2004) recommend (see WHO/UNICEF/UNFPA/UNAIDS. 2003. HIV and infant feeding listed in Appendix 3).

BOX 10 · EXCLUSIVE BREASTFEEDING

Exclusive breastfeeding means an infant receives only breastmilk from the mother or a wet nurse, or expressed breastmilk, and no other liquids or solids except drops or syrups consisting of vitamins, mineral supplements or medicines.

If the mother is HIV- or of unknown HIV status

Most babies should breastfeed exclusively for six months

Advise the mother to exclusively breastfeed until the baby is six months (180 days) old.

Breastmilk contains all the nutrients a full-term baby needs for the first six months of life. It provides enough water even in hot weather and is the safest source of water.
Exclusive breastfeeding reduces the risk of diarrhoea and other infections. Giving any other food or drink increases the risk of diarrhoea.
Exclusive breastfeeding means the mother is unlikely to become pregnant.

Breastmilk provides all the food and water young babies need

Ways to encourage exclusive breastfeeding include:

helping the baby to start suckling within one hour of birth - the mother and baby should be in skin contact immediately after birth;
if necessary, explaining why colostrum is an essential food for newborn babies. Colostrum contains high levels of vitamin A and anti-infective factors that protect newborns from disease. Giving colostrum is like giving a first immunization. If a family has a wrong belief about colostrum (e.g. it is dirty), help them to understand it is safe, and is the perfect food for their new baby;
checking that the baby is suckling correctly (see Figure 9);
if necessary, explaining why families should not give baby any other food or drink (even traditional drinks);
advising the mother to feed ‘on demand’ (when the baby wants to feed) at least 8-10 times over 24 hours, and let the baby suckle for as long as he or she wants day and night;
dealing with breastfeeding problems (e.g. sore nipples, engorged breasts, thrush in baby’s mouth) promptly;
teaching the mother how to express and store her milk if she is away from her baby for more than three hours;
referring the mother to a local breastfeeding support group if there is one.

Figure 9. Suckling in the correct position

Baby’s body is turned towards mother, the chin touches mother’s breast, the mouth is wide open and both lips are turned outwards. More areola is above than below baby’s mouth. The baby takes slow deep sucks and you can hear the baby swallowing.

Colostrum is the best and safest food for newborns

Also advise families that breastfeeding mothers need:

extra food (the equivalent of one extra small meal a day). They especially need more meat, poultry, offal and fish, and more vegetables and fruits;
enough drink so they are not thirsty;
more rest if possible.

Make sure mothers know that HIV can be passed to their babies through breastmilk and how to avoid that their babies become infected.

If the mother is HIV+

Explain the risks and benefits of breastfeeding and replacement feeding to HIV+ mothers and their partners before the baby is born

While the mother is still pregnant:

explain to her the risk of the virus being passed to her baby through breastmilk;
explain and discuss the risks and benefits of exclusive breastfeeding and of replacement feeding, and the risks of feeding breastmilk with other foods (see Box 11, page 56).

Replacement feeding means feeding a child who is not receiving breastmilk with a diet that provides all the nutrients the child needs. During the first six months this should be a suitable breastmilk substitute, such as commercial or home-made formula.

BOX 11 · RISKS AND BENEFITS OF DIFFERENT WAYS OF INFANT FEEDING

Exclusive breastfeeding

It gives immunity from other infections, is the best source of nutrients and safe water, reduces the risk of pregnancy and prevents the possible stigma of not breastfeeding.
There is a risk of passing HIV to the baby but this is lower if:

- the mother gives no other food or drink;
- the mother does not have cracked nipples or mastitis, or is not clinically ill with AIDS;
- the baby does not have sores or thrush in the mouth.

Replacement feeding

There is no risk of passing HIV to the baby.
There is a high risk of diarrhoea and other infections if the family lacks the resources to buy and prepare other milk feeds safely.
There is a risk that the caregiver will prepare the feed incorrectly (e.g. overdilute it) so that the child becomes malnourished.
There is the possibility of stigma and of others knowing the mother’s HIV status.

Replacement feeds should only be given where they are acceptable, feasible, affordable, sustainable and safe.

Feeding both breastmilk and breastmilk substitutes

There is a higher risk of passing HIV to the baby than with exclusive breastfeeding.
There is a risk of other infections and malnutrition if breastmilk substitutes are not prepared safely and correctly.

When a HIV+ mother has decided how to feed her baby, give her support and advice. If the mother agrees, try to talk with relatives (e.g. her husband, partner and/or mother) so they can also support and help her.

If the mother decides to breastfeed:

strongly advise her to start exclusive breastfeeding immediately after birth, and not to give any other food or drink. Advise her to exclusively breastfeed for the first few months and up to six months. When she wants to stop breastfeeding, she should do this when the family is able to give suitable replacement feeds;
take time to explain the risks of feeding breastmilk with other foods;
counsel her on how to exclusively breastfeed (see above);
advise her to immediately seek health care if she has cracked nipples, engorged breasts or if her baby has sores or thrush in the mouth;
counsel, in advance, on how to stop breastfeeding as this should be done at an earlier age and over a shorter period than usual, and the mother needs to plan for this change (see Box 12);
weigh the baby at least monthly to monitor his or her growth.

BOX 12 · STOPPING EXCLUSIVE BREASTFEEDING FOR HIV+ MOTHERS

HIV+ mothers should stop breastfeeding over a shorter period than usual (i.e. the change-over period from exclusive breastfeeding to replacement feeding should last only about two weeks or less). This is because the baby is at higher risk of HIV infection during the change-over period.

However, ceasing breastfeeding over a short period increases the risk of difficulties such as mastitis and breast abscesses, and objections from families - and the babies may become distressed and lose their appetites.

To help mothers and babies during the change-over period, health workers can:

show a mother how to express her breastmilk and then heat-treat it (heattreating destroys the HIV virus). This reduces the risk of engorgement for the mother and allows the baby to continue receiving breastmilk while becoming used to the tastes of replacement feeds and to cup feeding. To heat-treat breastmilk, put the milk in a small pot, heat until the milk boils and then put the pot into a container of cold water so the milk cools quickly;
advise a mother (and her relatives if possible) on suitable replacement feeds and how to prepare them. Babies aged less than six months should receive only breastmilk substitutes (home-made or commercial infant formula) or heattreated breastmilk. After that they should also have complementary feeds (see Topic 7);
tell a mother to give extra attention and love to her baby and to give replacement feeds or expressed heat-treated breastmilk herself;
advise a mother to seek health care immediately if she has any signs of mastitis and/or sore nipples;
if appropriate, explain to relatives the reasons for ceasing breastfeeding earlier than usual.

If the mother decides not to breastfeed:

advise the mother (or other caregiver) not to give any breastmilk (unless expressed and heat-treated). Emphasize the risks of giving both breastmilk and other foods;
check that the family has the resources and skills for making and giving replacement feeds;
show the mother how to prepare the feeds and how to feed with a cup. Emphasize the need for good hygiene and for diluting the milk correctly. Explain the risks of using a bottle (e.g. they are difficult to clean and so increase the risk of diarrhoea);
watch the mother prepare and give a feed and correct any mistakes. Try to do this in her own home using her own equipment;
encourage the mother to feed the baby herself and to cuddle him or her as often as possible;
if appropriate, talk with the mother’s relatives (e.g. her partner or mother) and explain what they can do to support and help her;
tell the family to take the baby quickly to a health worker if there are any feeding or health problems.

Monitoring baby’s weight

Babies aged 0-6 months should be weighed at least monthly. Plot the weights on a growth chart and make sure the mother or caregiver understands the growth curve (see Topic 11, page 89). This is especially important for children whose mothers are HIV+.
Give any necessary advice and support on feeding and care (see Topic 11). Topic 7 explains when to start complementary foods.
Give vitamin A supplements according to national protocols.

SHARING THIS INFORMATION

Before sharing this information with families, you may need to:

1. Find out. How local babies aged 0-6 months are fed. Whether mothers exclusively breastfeed, and if so, for how long. If not, which other foods, water or other drinks are given. What the blocks to exclusive breastfeeding for six months are. How women who are HIV+ feed their babies. What their knowledge of the risks and benefits of different feeding methods is. Who decides how babies are fed. What advice and resources are needed by mothers who decide not to breastfeed. Which breastmilk substitutes are available locally and what their costs are. What breastfeeding women do if they have breastfeeding problems, such as sore nipples or engorged breasts, or if their babies have thrush.

2. Prioritize. Decide which information is most important to share. This may depend on whether you are communicating with groups of mothers or parents, with individual HIV+ mothers, with mothers who are HIV- or whose status is unknown, or with traditional midwives.

3. Decide whom to reach. For example: mothers, other caregivers and, if appropriate, their partners and other relatives; traditional midwives.

4. Choose communication methods. For example: individual counselling and group discussions at antenatal and postnatal clinics, in maternity wards and at young child clinics; demonstrations of suckling position, replacement feeding and heat-treating expressed breastmilk.

Examples of questions to start a discussion
(choose only a few questions that deal with the information families need most)

What is exclusive breastfeeding? Why do we recommend exclusive breastfeeding?

Why is colostrum an excellent food for newborns? Do we give colostrum to our babies? If not, why not?

Do breastfed babies need extra water?

What foods or drinks other than breastmilk do we sometimes give young babies? Why? Could we stop doing this?

What should women who have sore nipples or engorged breasts do?

Do breastfeeding women need extra food? Which foods are good for breastfeeding women?

Discuss the feeding of babies of HIV+ mothers only if a group wants to. Do this in a sensitive way. Otherwise counsel mothers individually.

Can the virus be passed to a baby through breastmilk? Explain that the risk may be less if a baby is exclusively breastfed.

What are the dangers of replacement feeding? Explain the risks and benefits of both exclusive breastfeeding and replacement feeding. Explain the risks of giving both breastmilk and breastmilk substitutes.

How can breastmilk be made safe during the time that a mother is changing from exclusive breastfeeding to replacement feeds? Explain why and how to express and heat-treat breastmilk.

If replacement feeding occurs in the area

Which breastmilk substitutes are available and used here? How much do they cost? Do mothers know how to prepare them in a safe and hygienic way? Are they culturally acceptable?

Why is it dangerous to feed with a bottle? Do women know how to feed with a cup?

Demonstrate preparing and giving a feed using a breastmilk substitute that local families can afford.