Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 170-174  

A study of feeding practices among infants born to HIV-infected mothers and its association with morbidity in infants


1 Department of Community Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre Dr D Y Patil Vidyapeeth, Pimpri, Pune, India
2 Department of Preventive and Social Medicine, Seth G S Medical College and K.E.M. General Hospital, Parel, Mumbai, India
3 Department of Preventive and Social Medicine, Terna Medical College, Navi Mumbai, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Megha S Mamulwar
F 19, Plot 114, GMC Nirmiti, Behind RTO Office, Purnanagar, Sec CDC, Chikhali Pradhikaran, MIDC Chinchwad, Pune - 411 014
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.110309

Rights and Permissions
  Abstract 

Context: Globally, 2.3 million children have been victims of Human Immunodeficiency Virus (HIV) as of December 2006. Transmission through breastfeeding (BF) is estimated to account for one third to one half of all these pediatric HIV infections. Aim: To study the feeding practices followed by HIV-infected mothers in Mumbai. Settings and Design: It is a prospective observational type of study conducted in a tertiary care hospital with antiretroviral treatment center for a period of one year. Materials and Methods: The study was reviewed and approved by the ethical committee of the hospital. Babies aged 0 to 9 months and born to HIV-positive mothers who are brought to integrated HIV outpatient department were included in the study. Statistical Analysis Used: The data entry and analysis was done using SPSS 15 package, Microsoft Excel 2003, and Epi Info. Results: As per the findings of this study, proportion of exclusive BF was 34.2%, top feeding was 42.1%, and mix feeding (MF) was 23.7%. Diarrhea occurred more frequently in mix-fed infants (53.6%) as compared to exclusively breast-fed infants (2.5%) and top-fed infants (12.7%). The percentage of infants who were exclusively breast fed and had normal weight for age was 53.8%. Moderately malnourished infants were 30.8% and 15.4% of infants were severely malnourished. The percentage of severe malnutrition was more in top-fed and mix-fed infants (23.4% and 32.1%, respectively). Conclusion: MF was associated with increased risk of diarrhea and acute respiratory infection. Top-fed and mix-fed infants were more likely to suffer from infectious diseases.

Keywords: Exclusive breastfeeding, feeding practices, human immunodeficiency virus, mix feeding, top feeding


How to cite this article:
Mamulwar MS, Hadaye RS, Pandit DD. A study of feeding practices among infants born to HIV-infected mothers and its association with morbidity in infants. Med J DY Patil Univ 2013;6:170-4

How to cite this URL:
Mamulwar MS, Hadaye RS, Pandit DD. A study of feeding practices among infants born to HIV-infected mothers and its association with morbidity in infants. Med J DY Patil Univ [serial online] 2013 [cited 2024 Mar 28];6:170-4. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/2/170/110309


  Introduction Top


Globally, 2.3 million children have been victims of Human Immunodeficiency virus (HIV) as of December 2006. [1] It claims more than half a million young lives every year. [2] In India, there are 5 596 cases of Acquired Immunodeficiency (AIDS) in the age group of 0 to 14 years as of December 2006. [1] Transmission through breastfeeding (BF) is estimated to account for one third to one half of all these pediatric HIV infections. Without intervention, the risk of transmission from an infected mother to her child ranges from 15% to 25% in developed countries and from 25% to 45% in developing countries. This difference is largely attributed to BF practices followed in these regions. [3] As per the recent guidelines given by WHO (2010), HIV-positive mothers are recommended to breastfeed until 12 months of age when antiretroviral medicines are available. [4] In situations where antiretroviral medicines are not available, mothers should be counseled to exclusively breastfeed in the first six months of life and continue BF thereafter unless environmental and social circumstances are safe for and supportive of replacement feeding. [4] Replacement feeding is done only when the AFASS criteria (A - Acceptable, F- Feasible, A - Affordable, S - Sustainable, S - Safe) is fulfilled. [4] Thus, there is a dilemma in front of HIV-infected mothers whether to breastfeed her child or not. She is completely dependent on the information given by her healthcare provider regarding infant feeding in HIV to take a decision about feeding of her child. It is very important to know what mothers understand by this dual policy and what they follow. Hence, this study was planned with an aim to study the feeding practices followed by HIV-infected mothers and its association with morbidity in infants, in Mumbai.


  Materials and Methods Top


It is an observational prospective type of study conducted from August 2005 to April 2008. A tertiary care hospital with the Antiretroviral Treatment Center in the city of Mumbai was selected for the study. The study was reviewed and approved by the ethical committee of the hospital. Sample size was calculated using the following formula. [5]

n = Z 2 1-α/2 p (1-p)/d 2

Specifications:

n = number of respondents

Z = 1.96

α = Type I error (0.05)

P = Anticipated prevalence of exclusive BF (EBF) in seropositive mothers was taken from literature [6]

d = absolute precision required on either side of proportion

(10 percentage points)

A sample of 114 was taken with 10% addition for loss to follow up.

Sampling unit was mother-baby pair in which mother is diagnosed as HIV positive. HIV status of the child was not known. At the time when the study was carried out (2005-2008), the guidelines were to do ELISA for the child when the child is 18 months of age and DNA PCR test was recommended before 18 months of age which was very costly and beyond the available resources.

Inclusion criteria

Babies aged 0 to 9 months and born to an HIV-positive mother and brought to outpatient department were included in the study.

Exclusion criteria

  • The infant whose informant (when mother was not able to come to clinic) was not in possession of the child for at least a period of 1 month was excluded from the study.
  • Mothers whose HIV status was detected after the feeding practice was established.
  • Mother expired before the feeding practices were established.
  • Mothers who were not willing to participate.


B. G. Prasad's revised classification of economic status was used to categorize the respondents. [7]

Written informed consent was obtained from the respondents who were willing to participate. A pilot study was carried out to standardize the interview schedule. Based on the above mentioned criteria, mothers of the selected babies were interviewed with the help of pretested interview schedule for the feeding practices of their child. Mothers who were found mixed feeding their child were interviewed in detail (informal discussion) to get the qualitative data about the reasons behind mixed feeding. All study participants were interviewed again after an interval of 3 months to study any change in feeding practices and its effect on morbidity in infants.

WHO infant feeding guidelines were used to define feeding practices.

Exclusive breastfeeding

An infant receives only breast milk and no other liquids or solids, not even water, with the exception of drops or syrups consisting of medicines, vitamins, and mineral supplements. [8]

Top feeding

Feeding a child on artificial foods (including infant formula and powdered or modified animal milk) and not BF at all. [9]

Mix feeding

BF while giving nonhuman milk such as infant formula or food-based fluid or solid food. Even a single event of such feeding was taken as mix feeding (MF). [10]

Confidentiality was maintained about the data provided by the respondents by giving each case record form a unique identification number. The data entry and analysis was done using SPSS 15 package, Microsoft Excel 2003, and Epi Info.


  Results Top


The percentage of infants included in the study who were in the age group of 0 to <2 months was 56.1%. With an aim to study the feeding practices followed by the mother, an attempt was made to enroll them as early as possible. In spite of this, 25.4% could be enrolled late at the age of ≥6 to <9 months. Mean age of the infants included in the study was 2.9 months. 45.6% of infants were male and 54.4% were female [Table 1]. The percentage of mothers who completed their secondary education was 38.6% and 34.2% were illiterate. 85.7% of mothers were unemployed (Housewives). Socioeconomic status of 36.2% mother-baby pairs was upper lower class.
Table 1: Sociodemographic characteristics (n = 114)


Click here to view


All the mothers included in the study either chose to breastfeed or top feed their baby based on the counseling done at time of delivery by a counselor and a pediatrician. The percentage of mothers who opted to breastfeed their baby at the time of delivery but were not able to adhere to it was 17.5%. The reasons given by these mothers for initiating top feeding (TF) along with BF were perceived inadequacy of breast milk (45%), morbidity in mother (25%), advised by doctor to stop BF at 3-4 months (25%) but were not able to stop BF abruptly, and fear of HIV transmission (5%). There were 6.1% of mothers who initially opted to top feed their baby; however, due to various reasons like stigma (28.6%), financial constraint to buy formula (28.6%), time required to prepare formula milk, and familial pressure to breast feed the child (28.6%), these mothers started BF their child along with TF. Hence, these both type of practices were categorized separately as mixed fed category for analytical purposes. The proportion of various feeding practices in study population was calculated [Table 2]. The proportion of exclusively breast-fed infants was 34.2%, proportion of top-fed infants was 42.1%, and proportion of mix-fed infants was 23.7%.

The percentage of MF increased with the age of the infant; maximum MF occurred after the age of 4 months. This distribution was statistically significant. In this study, it was observed that the percentage of mothers from lower socioeconomic status who opted for TF was 30.5% and the percentage of mothers who switched over to MF was 33.9%.
Table 2: Distribution of respondents according to feeding practices followed by them at the time of enrollment (n = 114)


Click here to view


Among the mothers who completed their primary education or less the percentage of EBF was 37.7%, TF 31.1%, and MF 31.1%. Mothers who completed their secondary education or more were more likely to top feed their child (52.8%). The percentage of EBF and MF was 30.2% and 17%, respectively, in the mothers who had completed secondary or more education. This distribution was statistically significant. The percentage of mixed feeding was least (17%) in mothers who completed their secondary or more education as compared to mothers who were illiterate and mothers who had completed primary education [Table 3].
Table 3: Association between feeding practice with age of infant and education of mother


Click here to view


There was a significant effect of feeding practice on the morbidities seen in infants as reported at the time of enrollment into the study [Figure 1]. Diarrhea, acute respiratory infections (ARIs), and skin rash were most commonly reported morbidities.
Figure 1: Component bar diagram showing association between feeding practice and morbidity at the time of enrollment in the study, EBF: Exclusive breast feeding, TF: Top feeding, MF: Mix feeding

Click here to view


Diarrhea occurred more frequently in mix-fed infants (53.6%) as compared to exclusively breast-fed infants (2.5%) and top-fed infants (12.7%). The percentage of diarrhea in infants in mix-fed category and age more than 4 months was 50% of total diarrhea cases. The ARIs were seen mostly in infants who were mix fed or top fed.

In the exclusively breast-fed group, the percentage of infants who had normal weight for age was 53.8%, moderately malnourished infants were 30.8%, and only 15.4% of infants were severely malnourished. The percentage of severe malnutrition was more in top-fed and mix-fed infants (23.4% and 32.1%, respectively).

Of 114 enrolled mother-infant pairs, 56 pairs were followed up after 3 months. The remaining 58 pairs were not available for follow up as some of them were residing out of city and some were residing out of state. These 58 respondents were also not available for telephonic follow-up as either they change their phone numbers when they move to their native place or they did not have enough financial resources to keep their phone functioning. This huge loss to follow-up was an important limitation and also a matter of concern whether these mother-baby pairs need extra attention by outreach services to adhere to their feeding option. At the time of enrolment, of these 56 mothers, 31 were BF and 25 were TF their child. Adherence to the feeding choice at the time of follow up was 100% in top-fed group. Among the 31 mothers who were BF at the time of enrollment, 13 (41.9%) continued to breastfeed at the time of follow up. It was observed that the percentage of mothers who discontinued BF as per their doctor's advice at the time of follow up was 58.1%. There was no significant change in the morbidity profile at the time of follow up.


  Discussion Top


Male and female distribution in this study is almost similar to that in a study conducted in Pune (45.95% of male and 54.05% of female) and in another study conducted in Durban South Africa. [6],[10] In this study, the percentage of female infants is more as compared to male infants.

Maternal age was not significantly associated with adherence to feeding option which supports findings from similar studies in past. [11] A study conducted in Zimbabwe revealed the fact that MF increased predictably with the age of the infant. [12] These findings were comparable to this study.

Unlike similar studies conducted across the world, it was observed that education of the mother was associated with the feeding practices followed by them. [11],[13] Literacy of the mother was associated with increasing tendency to top feed their baby. Illiterate mothers were mostly from lower socioeconomic status. They did not have a role in the decision making process in the family, especially in financial matters, as a result of which they could not opt for top feeds and had to breastfeed their child. Mothers who had completed their secondary education or more were mostly from middle or upper middle class and could afford modified animal milk as a replacement feed for their child which is less costly as compared to formula milk. In two different studies, it was observed that maternal education was not significantly associated with adherence to feeding option. [11],[13]

Socioeconomic status has a significant impact on the feeding practices followed in a particular family. In spite of being enrolled in tertiary care center and being counseled about infant feeding in HIV, participants opted to top feed their baby in inappropriate situation. This is the impact of dual nature of the policy. Giving thorough counseling and understanding patients' situation is must as patients are overwhelmingly relying on the counselor and doctor to take decisions regarding feeding of the baby. [14],[15]

The morbidity percentage in EBF group was 15%. In TF and MF group, the percentage increased to 40% and 45%, respectively. Hence, the feeding practices followed have significant impact on the morbidity experienced by the infant. In this study, there was a significant effect of feeding practice on the number of episodes of diarrhea. MF was associated with increased risk diarrhea and also increased risk of HIV transmission. The most common morbidity observed was gastrointestinal infection followed by respiratory infection and skin rash. In this study, the period of occurrence of diarrhea coincides with the period of early weaning. HIV-infected mothers who chose to breastfeed their infants were advised to stop BF early, i.e., by the age of 4 to 6 months and start the child abruptly on top feeds. If top feeds were not introduced in a proper manner, then it resulted in diarrhea. In case of HIV-infected mothers, if she continues to breastfeed her child when child is having diarrhea due to top feeds, then the risk of transmission of HIV infection to the child is very high as compared to the risk involved in BF when the child is not having any diarrhea. Hence, BF along with top feed or complimentary feed is very risky for a child whose mother is infected with HIV. For a mother who is not infected with HIV, there is no risk of HIV transmission even if the child develops diarrhea at the time of weaning and hence mother can safely continue BF along with weaning food.

As per the recent WHO infant feeding guidelines, it has been recommended to breastfeed and mix feed in conjunction with antiretroviral treatment. HIV-infected mothers can now safely breastfeed their child provided that they or their infants receive ARV drugs during the BF period. This has been shown to give infants the best chance to be protected from HIV transmission in settings like India where BF is the best option. This has also helped the HIV-infected mothers in India to get rid of the dilemma of whether to breastfeed or top feed their young one.

If an HIV-infected mother is not counseled thoroughly for infant feeding practices to be followed in case of HIV infection, then she might opt for an inappropriate feeding practice. This will increase the incidence of infectious diseases drastically and will also lead to increased risk of HIV transmission. Extensive counseling and understanding socioeconomic condition of HIV-infected mother properly will help her to take a well-informed decision about the infant feeding.

These mothers should also be counseled at frequent intervals at the time of transition from EBF to TF. This well help in avoiding MF during this transition. Stepwise weaning process to be followed during transition phase of changing over from breast feed to top feeds. In the first step, baby should be accustomed to spoon feeding before switching over to top feeds by giving expressed breast milk. Weaning from suckling at the breast should be gradual process to avoid any physical and mental disturbances in mother as well as the infant. In the second step, breast milk should be stopped completely and suddenly. As soon as the baby accepts all the feeds as expressed feeds including night feeds, baby can be switched over to top feeds. Repeated counseling before and during the transition phase is the key to prevent MF.


  Acknowledgement Top


Authors wish to express their sincere thanks to Dean, LTMMC and LTMGH Sion Mumbai, Head of Dept Pediatrics and Medicine, LTMMC and LTMGH Sion Mumbai for permitting us to conduct this study.

 
  References Top

1.UNAIDS/WHO (2006) epidemic update. 2006. Available from: http://www.unaids.org/en/ HIV_data/epi2006/default.asp [Last accessed on 2012 May 10].  Back to cited text no. 1
    
2.UNAIDS, Global Summary of the HIV and AIDS epidemic. Available from: http://www.unaids.org [Last accessed on 2004 Dec].  Back to cited text no. 2
    
3.Indian Academy of Pediatrician NACO with support from Clinton Foundation, UNICEF, WHO. Guidelines for HIV care and treatment in infants and children. New Delhi: Macro Graphics (P) Ltd; 2006. p. 3.   Back to cited text no. 3
    
4.WHO, UNAIDS, UNFPA, UNICEF Guidelines on HIV and infant feeding 2010. Available from: http://.www.who.int/child_adolescent_health/documents/.../index.html [Last accessed on 2012 May 10].  Back to cited text no. 4
    
5.Work Shop on sample size consideration in Medical research. Dept of Preventive and social Medicine, Govt. Medical College Nagpur, India and Maharashtra Chapter of Indian Association of Preventive and Social Medicine. Aug 1999, p. 34.  Back to cited text no. 5
    
6.Phadke MA, Gadgil B, Bharucha KE, Shrotri A, Sastry J, Gupte NA, et al. Replacement feed infants born to HIV infected mothers in India have a high early postpartum rate of hospitalization. J Nutr. 2003;133:3153-7.  Back to cited text no. 6
    
7.Parashar SSL. Socio-Behavioural Science and Health. In Bhalwar R,Editor.Public Health and Preventive Medicine. The Red Book; 7 th ed. Pune: Department of Community Medicine; 2000, p. 421.  Back to cited text no. 7
    
8.Brown KH, Black RE, Roma˜na GL, Kanashiro HC. Infant feeding practices and their relationship with diarrhoeal and other diseases in Huascar (Lima), Peru. Pediatrics 1989;83:31-40.   Back to cited text no. 8
    
9.Kulkarni AP, Baride JP. Text Book of Community Medicine. 1 st Ed. Agarwal Bhawan, Kidwai Marg, Wadala, Mumbai: M/s Vora Medical Publications; 1998. p. 24-5.   Back to cited text no. 9
    
10.Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM, for the South African Vitamin A Study Group: Influence of infant feeding patterns on early mother to child transmission of HIV-1 in Durban, South Africa: A prospective cohort study. Lancet 1999;354:471-6.  Back to cited text no. 10
    
11.Bland RM, Rollins NC, Coovadia HM, Coutsoudis A, Newell ML. Infant feeding counseling for HIV infected and uninfected women: Appropriateness of choice and practice. Bull World Health Organ 2007;85:289-96.  Back to cited text no. 11
    
12.Gottlieb D, Shetty AK, Mapfungautsi RM, Bassett MT, Maldonado Y, David A. Infant feeding Practices of HIV infected and uninfected women in Zimbabwe. AIDS Patient Care STD's 2004;18:45-53.  Back to cited text no. 12
    
13.Kiarie JN, Richardson BA, Mbori-Ngacha D, Nduati RW, John-Stewart GC. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr 2004;35:75-81.  Back to cited text no. 13
    
14.Shankar A, Sastry J, Erande AS, Joshi A, Suryavanshi N, Phadke MA, et al. Making the choice: The translation of global HIV and infant feeding policy to local practices among mothers in Pune-India. J Nutr 2005;135:960-5.  Back to cited text no. 14
    
15.Rollins N, Meda N, Becquet R, Coutsoudis A, Humphery J, Jeffrey B, et al. Preventing postnatal transmission of HIV-1 through Breast Feeding: Modifying infant feeding practices. J Acquir Immune Defic Syndr 2004;35:188-95.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Acknowledgement
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed2665    
    Printed137    
    Emailed0    
    PDF Downloaded309    
    Comments [Add]    

Recommend this journal