Bibliographic Info
Recommendation
Recommended in favor
Strong
Certainty of evidence
Low
When mothers known to be HIV-infected decide to stop breastfeeding at any time, infants should be provided with safe and adequate replacement feeds to enable normal growth and development. Alternatives to breastfeeding include: 1) For infants less than six months of age: — Commercial infant formula milk as long as home conditions outlined in Recommendation #5 are fulfilled; — Expressed, heat-treated breast milk (see Recommendation #6). Home-modified animal milk is not recommended as a replacement food in the first six months of life. 2) For children over six months of age: — Commercial infant formula milk as long as home conditions outlined in Recommendation #5 are fulfilled; — Animal milk (boiled for infants under 12 months), as part of a diet providing adequate micronutrient intake; — Meals, including milk-only feeds, other foods and combination of milk feeds and other foods, should be provided four or five times per day. 3) All children need complementary foods from six months of age
Notes and Remarks
- 1)There was little direct evidence from HIV-exposed populations to inform this recommendation (Grade profile 4, Annex 4). Only a few reports were identified that provide information about the experiences of HIV-infected mothers in providing an adequate diet to their infants after they have stopped breastfeeding (30–32). These reports consistently noted that mothers had difficulty providing adequate diets, and that there was little support from health services to assist them at these times.
- 2)A WHO technical consultation in 2005 resulted in guiding principles for feeding nonbreastfed children 6–24 months. The consultation noted that milk is an important part of an infant’s diet and that it is difficult to formulate a safe and adequate diet for infants between 6 and 12 months of age without milk of some kind. Commercial infant formula milk can provide the necessary nutritional content but is subject to the same safety concerns, namely hygienic preparation and clean water supply, that are of even greater concern in the first 6 months of life. After 6 months of age, infants (whether HIV-exposed or not) can safely be given whole cow’s milk as a primary source of milk, but until 12 months the milk should be boiled, and additional liquids should be given.
- 3)The group considered that the very considerable evidence from non HIV-exposed populations was relevant and justifiable to use to inform how HIV-infected mothers should feed their infants in the absence of breast milk. The prevalence of growth faltering and moderate malnutrition due to poor complementary feeding practices after 6 months of age (38) highlights the importance of milk (or other animal-source foods) in the diets of infants from 6 to 12 months.
- 4)The explicit statement that home-modified animal milk should not be used as a replacement feed in infants less than 6 months of age was included in the 2006 WHO recommendations on HIV and Infant Feeding (39); the group considered it important to include it in these recommendations again.