Breastfeeding vs Formula-Feeding Among HIV-Infected Women in Resource-Poor Areas

Published in the Journal of the American Medical Association (JAMA)
on March 6, 2002

To the Editor:

Dr Mbori-Ngacha and colleagues1 concluded that "formula-fed infants [of HIV-1–positive mothers] had a better outcome than breastfed infants." We disagree with this conclusion because it was based on the assumption that the death rate among breastfed infants will eventually be higher due to their higher likelihood of being HIV-1–positive.

Mbori-Ngacha et al also found a similar incidence of diarrhea in the 2 study groups, which seems to contradict the results of other research2, 3. However, Table 2 in their article shows that dehydration was more common among the formula-fed infants. It is dehydration, not diarrhea, that leads to mortality in infants.

Although the difference was not statistically significant, more than twice as many HIV-1–positive infants (29% vs 14%) were malnourished in the formula group, and the rate of malnutrition was higher in the formula fed HIV-negative infants as well (11% vs 7%). If this trend were replicated in a larger trial, it could indicate that the negative health effects of formula feeding extend beyond 2 years.

Mbori-Ngacha et al claim that their trial compares breastfeeding with formula feeding. However, it actually compares mixed feeding with mixed feeding because the treatment groups were defined inconsistently and an intent-to-treat analysis was used. Thirty percent of the women in the "formula" group were listed as noncompliant if they breastfed even once, but women in the "breastfeeding" group could use any amount of formula4. Consequently, the reported 96% compliance in the breastfeeding group is likely a significant overestimate.

In summary, it is possible that either the apparent higher levels of malnutrition experienced by infants in the formula-fed group or their higher susceptibility to dehydrating diarrhea could result in a higher mortality rate after age 2 years despite the higher prevalence of HIV-1 in the breastfed group.2, 3 Which group will ultimately have a higher mortality rate is at this point merely a matter of speculation. Public policy should not be based on assumptions. Until the true, long-term health consequences of the 2 approaches can be established by more tightly controlled trials with treatment groups that follow up infants with more distinct feeding patterns, we believe that the safest alternative is exclusively breastfeeding5.

Andrea Eastman, MA, IBCLC, Chairman, AnotherLook
Marian Tompson, Executive Director, AnotherLook
Carol Brussel, BA, IBCLC
Phyll Buchanan
David Crowe, HBSc
Judy LeVan Fram, PT, IBCLC
Jay Hathaway
Valerie W. McClain, IBCLC
Pamela Morrison, IBCLC
Magda Sachs, BA, MA

AnotherLook
Evanston, Ill

1. Mbori-Ngacha D, Nduati R, Grace J, et al. Morbidity and mortality in breastfed and formula-fed infants of HIV-1–infected women: a randomized clinical trial. JAMA. 2001;286:2413-2420.

2. Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics. 2001;108:e67.

3. Betran AP, de Onis M, Lauer JA, Villar J. Ecological study of effect of breast feeding on infant mortality in Latin America. BMJ. 2001;323:303-306.

4. Nduati R, Grace J, Mbori-Ngacha, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA. 2000;283:1167-1174.

5. Coutsoudis A, Pillay K, Kuhn L, Sponger E, Tsai WY, Coovadia HM, for the South African Vitamin A Study Group. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS. 2001;15:379-387.

Acknowledgment

We thank F. Railhet, MD, for her contributions to this letter.