12 February 2002

To the Editor of the Journal of Human Lactation:

The paper by de Paoli et al is a valuable addition to the study of breastfeeding in a climate of fear of HIV and AIDS. It increases our understanding of breastfeeding patterns in East, Central, and Southern Africa. It recognizes the importance of exclusive breastfeeding, and the need for a strict definition of this practice. We endorse their recommendation for intensive efforts to promote exclusive breastfeeding by educating health workers and mothers. Working to encourage and support exclusive breastfeeding has the potential to have a positive impact on families because it can be promoted for all women. It also maximizes resource use and it stigmatizes no one.

Readers of this paper may assume that although exclusive breastfeeding is an ideal goal, it is not achievable in practice, and that therefore formula feeding, ranked equal in HIV transmission risk to exclusive breastfeeding by Coutsoudis et al 1, might be preferable to the mixed feeding that would otherwise occur. While there are challenges to instituting widespread exclusive breastfeeding, too little attention has been paid to the fact that there are even greater constraints in achieving exclusive formula feeding in populations where this has rarely been practiced before.

Nearly all research on breastfeeding by HIV-positive mothers has used HIV-infection as the major or only end-point. A more meaningful end-point would be to compare death rates or rates of serious health problems in groups with well-defined feeding practices. The oft-quoted work of Nduati et al 2 was unable to find any difference in death rates between breastfed and formula fed babies by two years. It has been pointed out that feeding practices were defined so broadly that both groups contained a large percentage of mixed feeders3.

In a recent European study 4 22% of HIV-infected children had progressed to AIDS or death by 10 years, considerably lower than the rates of progression often seen in adults 5. Even if the rate of HIV transmission in breastfed babies may truly be higher than in formula fed babies, there is still no evidence that overall health outcomes are better in formula fed infants than in breastfed infants born to HIV-positive mothers.

Should breastfeeding be presumed guilty or innocent? Since the negative health consequences of formula feeding are well documented for all mothers, and the negative health consequences of breastfeeding by HIV-positive mothers are not, we recommend a presumption of innocence.

For AnotherLook:

Andrea Eastman, MA, IBCLC,
Chairman, AnotherLook
USA

Marian Tompson
Executive Director, AnotherLook
USA

David Crowe, HBSc
Canada

Sylvia Boyd, PT, LCCE, CLE, IBCLC
USA

Carol Brussel, BA, IBCLC
USA

Judy LeVan Fram, PT, IBCLC
USA

Ted Greiner, PhD
Sweden

Jay Hathaway, AAHCC
USA

Valerie W. McClain, IBCLC
USA

Pamela Morrison, IBCLC
Zimbabwe

Magda Sachs, BA, MA
United Kingdom

Francoise Railhet
France

References

1. Coutsoudis A et al. Method of feeding and transmission of HIV-1 frommothers to children by 15 months of age: prospective cohort study fromDurban, South Africa. AIDS. 2001 Feb 16; 15(3): 379-87.

2. Nduati R et al. Effect of breastfeeding and formula feeding on transmission of HIV-1; a randomized clinical trial. JAMA. 2000 Mar 1; 283: 1167-74.

3. Tompson M et al. Nduati's claim that breastfeeding HIV-positive mothers have higher mortality may be unwarranted. Lancet. 2001 Sept 29; 358(9287): 1095. [correction appeared 2001 Dec 15; 358(9298)]

4. European Collaborative Study. Level and pattern of HIV-1-RNA viral load over age: differences between girls and boys? AIDS. 2001 Jan 4; 16(1): 97-104.

5. Muñoz A et al. The incubation period of AIDS. AIDS. 1997; Vol 11 (suppl A): S69-76.