'A VITAL EMERGENCY RESPONSE'

  Libreville, 7 August 2009 -  More than 120 countries celebrated the 18^th annual World Breastfeeding Week to encourage breastfeeding as  a life saving intervention for infants  before and during emergencies this year. Complex challenges prevent many mothers from safely feeding their children in Africa, particularly in emergency situations. Educating African mothers,  health professionals, governments, aid agencies, donors and the media is the key to overcoming these challenges.  Rebecca JAMES reports

 Exclusive breastfeeding of infants in the first six months of life lowers infant mortality by providing ideal nutrition, reducing the incidence and severity of infectious diseases and improving infants' response to vaccinations.  It also contributes to women's health by reducing the risk of breast and ovarian cancer and by increasing the spacing between pregnancies. Breastfeeding is particularly important to protect infants in emergency situations, where child mortality can soar from 2 to 70 times higher than average due to diarrhoea, respiratory illness and malnutrition.

 UNICEF reports that many African countries have made major improvements in exclusive breastfeeding since 1990. These include Benin, Burkina Faso, Cameroon, Ghana, Madagascar, Mali, Nigeria, Senegal, Tanzania, Zambia and Zimbabwe. However, there are still significant challenges preventing widespread breastfeeding in Africa, particularly in Eastern/ Southern Africa which has the lowest regional exclusive breastfeeding rate in the world (20 percent).

 In sub-Saharan Africa, it is normal for a baby to be given water, teas, porridge or other foods as well as breast milk  even in the first weeks of life - due to both cultural traditions and  myths that mothers under stress or suffering from malnutrition are unable to breastfeed. Moreover, women that do choose to breastfeed are likely to stop in emergency situations due to mothers becoming ill or stopping lactating and the uncontrolled distribution of  large donations of infant formula and powdered milk from aid agencies, governments, companies and individuals. While these donations are largely attributable to marketing campaigns run by infant formula companies, irresponsible  media appeals  frequently reinforce them. In turn, this leads governments and aid agencies to commonly incorrectly assume formula is necessary. 

This is problematic as infant formula not only lacks the protective antibodies of breast milk, it is also impossible to safely prepare without clean boiling water and sterilised feeding implements.  

To prepare replacement foods and feed them to a baby several times per day for many months is challenging, even in the best of circumstances.  But emergencies can lead to water supplies being directly contaminated by faecal material in a number of ways: sewage pipes can be ruptured, water supply systems destroyed or human and animal waste washed indiscriminately into limited supplies of fresh drinking water. The temporary sanitation facilities available for large numbers of  displaced individuals in refugee camps also commonly lead to water supplies being contaminated, according to UNICEF. In these conditions, the use of infant formula is directly connected to the spread of infectious disease and increase of child mortality.  

The risk of mother-to-child HIV transmission: to breast-feed or not to breast-feed

 But as HIV-infected mothers can transmit HIV to their infants post-natally through breastfeeding, they must weigh up the risks and benefits of various infant feeding options to decide whether exclusive breastfeeding is best for their children. This is a pressing issue in sub-Saharan Africa, which is home to 2/3 of those – most of whom are women - suffering from HIV . 

On one hand, there is a 5-20% chance that HIV-positive women will pass on HIV to their infants through breastfeeding. The risk is cumulative over time and is highest where a woman has an increased viral load (where she has only recently contracted HIV herself/ is progressing towards AIDS after having HIV for a long time) or suffers from cracked nipples or mastitis. 

On the other, infants that aren't exclusively breastfed are at increased risk of dying from malnutrition, diarrhoea or a respiratory disease as the result of their weakened immune systems.  There are alternative methods of breastfeeding children without the threat of HIV transmission  - for example, employing a HIV-negative wet nurse or using donated breast milk from a milk bank. However, as it is culturally taboo for many African women to feed their babies another woman's breast milk, these alternatives are not often viable.

To balance the risk of HIV transmission against the risk of other causes of morbidity and mortality, there are specialised infant feeding guidelines for HIV-positive mothers. The guidelines clarify that  breastfeeding should only be avoided altogether in favour of replacement feeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe. Otherwise, exclusive breastfeeding is recommended during the first six months of life.  While the WHO recommends that counsellors assist women to apply these criteria to their own individual circumstances, this is a daunting task that is easier done in theory than it is in practice.  Of these criteria, safety – which essentially requires an evaluation of whether exclusive breastfeeding or replacement feeding is less likely to result in death in each case - is  the most difficult to determine. Numerous studies in Kenya, Cote d'Ivoire and Botswana have established that  replacement feeding can be beneficial, but not in all situations.

One such situation was Botswana in the aftermath of the 2005-2006 floods. Replacement feeding with infant formula had been offered to HIV-infected mothers as part of a national programme to prevent transmission of HIV from mother to child in 2005. However, flooding led to contaminated water supplies and a severe outbreak of diarrhoea and malnutrition in young children. An investigation of the post-flood deaths of more than 500 children found that nearly all the babies that died were formula fed. The use of infant formula also 'spilled over' to 15% of HIV-uninfected women that would otherwise have breastfed their children.

The 'spillover effect' to  HIV-negative women (or those unaware of their HIV status) and difficulty of safely preparing infant formula in emergencies are the precise reasons why UNICEF abolished the distribution of free infant formula to combat mother to child HIV transmission in 2002.

Another problem is the unhappy middle ground between the choices: many mothers  breastfeed non-exclusively (or mix-feed) in order to give their children the protection of breast milk and simultaneously reduce the risk of HIV transmission.  However, recent studies in Zimbabwe and South Africa have shown that mixed feeding leads to a 2-4 fold higher risk of HIV transmission than exclusive breastfeeding. In other words, a well-intentioned but uninformed mother trying to give her child the benefit of both options  will ultimately lose the benefit altogether. 

 Reducing the risk of mother to child transmission – Antiretroviral (ARV) treatments

 Various studies in Tanzania, Rwanda and Malawi have provided tentative indications that ARV treatments to either an HIV-positive mother or her child could be effective in reducing HIV transmission through breastfeeding. Furthermore, the results of a study more conclusively proving that ARV treatments can significantly reduce the risk of HIV transmission through breastfeeding were recently presented at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town.

Dr Charles Van der Horst from the University of North Carolina School of Medicine explained that 2, 637 mother infant pairs in Malawi were given uniform ARV treatment for a week. After that, the pairs were randomly assigned to receive either daily infant nevirapine syrup, twice daily maternal highly active ARV therapy, or no additional ARV therapy. The results after 28 weeks showed that the estimated risk of HIV transmission or infant death was significantly lower for the pairs where infants or mothers received ARV treatment – 2.9% and 4.7 % respectively - compared to 7.6% for the pairs not receiving treatment. It was not possible for mothers and infants to both receive ARV treatment simultaneously due to theoretical reasons of possible combined toxicities and the high cost of medications and monitoring,k Dr Van der Horst said.

By reducing the risk of mother-to-child HIV transmission in this way, ARV treatments may make it possible for HIV-positive women to safely breastfeed their children.

 Supporting mothers to support their children

 A primary objective of World Breastfeeding Week was to inform mothers, breastfeeding advocates, communities, health professionals, governments, aid agencies, donors, and the media on how they can actively support breastfeeding before and during an emergency.

Regardless of a mother's choice, she needs training and support – in breastfeeding and effective replacement feeding options -  to do the best thing by her child. There is ample proof that this practical training and support needs to come from health care workers. High rates of exclusive breastfeeding have generally been achieved in settings where mothers receive intensive counselling, education and support services.

Most notably, more mothers are feeding their infants and child health has improved in areas of 134 countries that are part of the Baby Friendly Hospital Initiative (BFHI). The BFHI is a UN initiative to get hospitals and maternity facilities to implement 10 specific steps to support successful breastfeeding and reject free or low-cost breast milk substitutes. It has been particularly successful in Gabon and Cameroon, which have incorporated it into more complex breastfeeding training and promotion strategies. 

Training on Infant Feeding in Emergencies conducted in the Dabaab refugee camp in Kenya also highlighted the need to develop effective training modules to adequately equip local health workers to work at a grass-roots level in emergency conditions.