Bibliographic Info
Recommendation
Recommended in favor
Strong
Certainty of evidence
Low
Mothers known to be HIV-infected should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status, when specific conditions are met: a. safe water and sanitation are assured at the household level and in the community; and b. the mother, or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant; and c. the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and d. the mother or caregiver can, in the first six months, exclusively give infant formula milk; and e. the family is supportive of this practice; and f. the mother or caregiver can access health care that offers comprehensive child health services.
Notes and Remarks
- 1)The group strongly endorsed this recommendation while acknowledging that the quality of direct evidence from HIV-exposed infants and their mothers was limited. (Grade profile 5, Annex 4) Furthermore, there is no possibility of conducting a clinical research study that would deliberately expose infants without the conditions listed above, to the risks of replacement feeding. It would be unethical to do so. However, the group considered the health outcomes of HIV-exposed infants from a range of programmatic settings and observational studies of HIV-exposed infants that indirectly reported on the influence of these household, environmental and social factors on child survival (7,12,40). The importance of high quality counselling to assist mothers make appropriate choices about infant feeding practices were noted (16,41).
- 2)The group also drew from programmatic experience and evidence from non-HIV populations in which there is considerable observational data that quantify the risks of not breastfeeding (1,2) and using commercial infant formula milk in settings that are sub-optimal.
- 3)The group also chose to explicitly define the conditions, using common everyday language, rather than referring to the acronym AFASS that was adopted in previous recommendations. It was felt that more carefully defining the environmental conditions that make replacement feeds a safe (or unsafe) option for HIV-exposed infants will improve HIV-free survival of infants. It was considered that such language would better guide health workers regarding what to assess, and to communicate this to mothers who were considering if their home conditions would support safe replacement feeding. Using these descriptions does not invalidate the concepts represented by AFASS.