text: 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;
  
  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
  
  Babys body is turned towards mother, the chin touches
  mothers breast, the mouth is wide open and both lips are turned outwards.
  More areola is above than below babys 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 mothers 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
  mothers 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 babys
  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.