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TitleNutrition in Infancy: Volume 2
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Table of Contents
                            Nutrition in Infancy
Series Editor
Series Editor Bios
Volume Editors Bios
Part I: Nutrition and Neonatal/Infant Disease
Part II: GI Tract Considerations
Part III: Hormones and Lipids: Growth and Development of Infants
Document Text Contents
Page 204

17914 Nutrition of Infants and HIV

macro- and micronutrients [ 28 ] . Numerous studies have been done identifying micronutrient
de fi ciencies in young infants with good evidence for single-micronutrient supplement bene fi ts—
particularly for vitamin A and zinc [ 19, 22, 29, 30 ] .

High quality and adequate complementary feeding is a necessity to avoid undernutrition including
stunting (very low height according to age [length/height-for-age < − 2 z-scores]) and wasting (weight-
for-length/height <−2 z-scores below the mean). Undernutrition is in many settings widespread at an
early age, particularly in Sub-Saharan Africa and South-East Asia, with up to half of the children
stunted at 2 years [ 19, 21, 22, 31 ] . Undernutrition has severe consequences in the short term with
increased vulnerability to morbidity and mortality, and also in the long term with less fortunate pros-
pects in adult life [ 19, 22, 32– 34 ] , and adds to the morbidity from exposure to HIV even when unin-
fected and the added risk of growing up without parents [ 3 ] .

Multiple factors seem to be involved in the causal web leading to stunting including environmental
and agricultural, economic, political, contextual factors, and in particular poverty, food security,
health, and care [ 19 ] . Studies have shown that undernutrition is strongly related with wealth—with
most undernutrition in the poorest part of the population [ 31, 35, 36 ] .

Good community programmes promoting adequate complementary feeding are highly diet and
context speci fi c, and drawing conclusions on which public health efforts are most ef fi cacious has been
dif fi cult. A review from 2008 indicated that food support in food insecure situations is bene fi cial in
terms of improving child growth [ 22, 86 ] .

Formula Feeding

While exclusive replacement feeding (complete avoidance of breastfeeding) nearly eliminates the risk
of postnatal HIV transmission from HIV-positive women to their infants, in many low- and middle-
income countries replacement feeding is not considered to be acceptable, affordable, feasible, sustain-
able, and safe.

Over the past several years, evidence has been accumulating from Africa on the increased mortal-
ity associated with formula feeding in various research studies focusing on prevention of mother-to-
child transmission of HIV (PMTCT) [ 10 ] . A pooled-meta analysis of studies in low-income countries
with low HIV prevalence found that infants who are not breastfed and receive formula milk or other
replacement feeding have a 6-fold increased risk of dying in the fi rst 2 months of life, a 4-fold increase
between 2 and 3 months, and a 2.5-fold increase between 4 and 5 months compared with those who
are breastfed [ 37 ] .

A trial in Botswana compared the ef fi cacy of exclusive breastfeeding combined with antiretroviral
drugs (zidovudine) given to the infant for 6 months vs. formula feeding combined with 1 month of
antiretroviral prophylaxis to the infant [ 38 ] . The HIV transmission rates at 7 months were 5.6% in the
formula-fed infants and 9.0% in the breastfed infants, while the number of infant deaths by month 7
was higher in the formula-fed group than in the breastfed infants (9.3 vs. 4.9%). Findings from Kenya
have suggested high mortality and transmission rates among both breastfed and formula-fed children;
however, in that study the HIV-free survival was slightly in favour of formula feeding in the study
context before the use of antiretroviral prophylaxis during breastfeeding [ 39, 40 ] .

Evidence of the dangers of formula feeding in non-research settings have also been documented in
Botswana. Between November 2005 and February 2006, there were unusually heavy rains and fl ooding
which led to an increase in the incidence of diarrhoea. Not breastfeeding was strongly associated with
diarrhoea and death, and most of the deaths were among HIV-exposed infants whose mothers were
receiving free formula milk through the PMTCT programme [ 41 ] . Recent evidence from Malawi has
also found that not being breastfed was signi fi cantly associated with declines in nutritional status as
evidenced by decreased mean length-for-age, weight-for-age and weight-for-length z-scores [ 42 ] .

In South Africa, research from routine PMTCT sites has found that an inappropriate choice to
formula feed (without WHO AFASS conditions being met) carries a greater risk of HIV transmission

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