![](media/image1.png){width="1.01875in" height="1.5833333333333333in"}

**Module 4** Infant Feeding in the Context of HIV Infection

**SESSION 1** Global Recommendations for Infant and Young Child Feeding

**Session 2** Feeding Options

**Session 3** Infant-Feeding Counselling and Support

**After completing the module, the participant will be able to:**

-   Describe the current global recommendations for infant feeding in
    the context of HIV.

-   Understand the importance of optimal infant and young child feeding
    for child health, nutrition, growth, and development.

-   Define the main options for infant feeding and the advantages and
    disadvantages of each.

-   Describe the steps for counselling mothers who are HIV-infected
    about infant feeding.

-   Understand the importance of the postnatal follow-up and support
    required for appropriate infant feeding.

+-----------------------------------------------------------------------+
| **Relevant Policies for Inclusion in National Curriculum**            |
+-----------------------------------------------------------------------+
| Session 2                                                             |
|                                                                       |
| -   National HIV infant-feeding policy and recommendations            |
|                                                                       |
| Session 3                                                             |
|                                                                       |
| -   National guidelines on infant-feeding counselling and support     |
+-----------------------------------------------------------------------+

  ---------------------------------------------------- -----------------------------------------------------------
  ![](media/image2.png){width="0.7597222222222222in"   The *Pocket Guide* contains a summary of each session in
  height="0.6263888888888889in"}                       this module.

  ---------------------------------------------------- -----------------------------------------------------------

SESSION 1 Global Recommendations for Infant and Young Child Feeding

Antiretroviral (ARV) treatment and prophylaxis has substantially reduced
mother-to-child transmission (MTCT) of HIV. ARV prophylaxis, however,
does not provide long-term protection for the infant who is
breastfeeding.

Without intervention, 5% to 20% of infants breastfed by mothers who are
HIV-positive may acquire HIV-infection through breast-feeding.
Infant-feeding practices that carefully follow national or UN guidelines
can reduce the likelihood of MTCT through breastfeeding and reduce the
risk of infant death from diarrhoea and other childhood infections.

Basic facts on malnutrition, infant feeding, and child survival

-   Malnutrition is the underlying cause of death in about 60% of
    children younger than 5 years old worldwide and in about 50% of
    children that age in Africa.

-   Being underweight was associated with 3.7 million deaths worldwide
    in the year 2000, and most of the deaths occurred in children
    younger than 5 years old.

-   Poor feeding practices, such as those that provide insufficient
    nutritional balance or contribute to diarrhoea, are a major cause of
    low weight and morbidity and mortality in children.

-   Counselling and support for infant feeding can improve feeding
    practices and, in turn, prevent malnutrition and reduce the risk of
    death in children.

-   For mothers who are HIV-positive, counselling and support may lead
    to improved infant-feeding practices that may also help prevent
    MTCT.

Infant-feeding recommendations for mothers who are HIV negative and
mothers with unknown HIV status

-   Breastfeed exclusively (see definition below) for the first six (6)
    months of life.

-   Continue breastfeeding for up to 2 years or longer.

-   After the infant reaches 6 months of age, introduce complementary
    foods that provide sufficient nutritional balance and are safe.

Mothers should also receive information about the risk of becoming
infected with HIV late in pregnancy or during breastfeeding. Women with
unknown HIV status should be encouraged to be tested for HIV.

> **Definition**
>
> **Exclusive breastfeeding:** The mother gives her infant only
> breastmilk except for drops or syrups consisting of vitamins, mineral
> supplements, or medicines. The exclusively breastfed child receives no
> food or drink other than breastmilk---not even water.

Infant-feeding recommendations for mothers who are HIV-positive

-   When replacement feeding is acceptable, feasible, affordable,
    sustainable, and safe, mothers who are HIV-infected should avoid all
    breastfeeding. (Please see "Definitions" below.)

-   Otherwise, exclusive breastfeeding is recommended during the first
    months of life.

-   To minimise HIV transmission risk, mothers who are HIV-positive
    should discontinue breastfeeding as soon as feasible, taking into
    account local circumstances, the individual woman's situation, and
    the risks of replacement feeding (which include malnutrition and
    infections other than HIV).

-   All mothers who are HIV-positive should receive counselling, which
    includes general information about the risks and benefits of
    infant-feeding options and specific guidance on selecting the option
    most likely to be suitable for their situation.

-   Whatever choice a mother makes, she should be supported.

    There is no evidence indicating a specific time for early cessation
    of breastfeeding for all mothers---as it depends on each mother's
    individual situation. *It is recommended that countries establish
    their own guidelines taking into account these recommendations.*

> **Definitions**
>
> **Acceptable:** The mother perceives no significant barrier(s) to
> choosing a feeding option for cultural or social reasons or for fear
> of stigma and discrimination.
>
> **Feasible:** The mother (or other family member) has adequate time,
> knowledge, skills, and other resources to prepare feeds and to feed
> the infant as well as the support to cope with family, community, and
> social pressures.
>
> **Affordable:** The mother and family, with available community and/or
> health system support, can pay for the costs of the replacement
> feeds---including all ingredients, fuel and clean water---without
> compromising the family\'s health and nutrition spending.
>
> **Sustainable:** The mother has access to a continuous and
> uninterrupted supply of all ingredients and products needed to
> implement the feeding option safely for as long as the infant needs
> it.
>
> **Safe:** Replacement foods are correctly and hygienically stored,
> prepared, and fed in nutritionally adequate quantities; infants are
> fed with clean hands using clean utensils, preferably by cups.

International Code of Marketing Breastmilk Substitutes

The importance of supporting safer infant-feeding practices is
exemplified in the International Code of Marketing of Breastmilk
Substitutes. This code helps provide safe and adequate nutrition for
children by:

-   Protecting and promoting breastfeeding

-   Supporting proper and informed use of breast-milk substitutes when
    necessary

-   Promoting acceptable marketing and distributing practices

Even in countries that have decided to provide infant formula to
HIV-positive mothers, health workers should resist all commercial
promotion of formula under the Code, for example by removing
advertisements from health facilities; refusing to accept free samples
of formula and equipment (e.g. bottles), refusing to accept or use other
gifts or equipment with brand names, and making sure that any formula
used in a health facility is kept out of sight of mothers who do not
need it.

+----------------+-----------------------------------------------------+
| Exercise 4.1   |                                                     |
| Strategies for |                                                     |
| optimal        |                                                     |
| feeding: large |                                                     |
| group          |                                                     |
| discussion     |                                                     |
+----------------+-----------------------------------------------------+
| Purpose        | To review strategies for optimal feeding of infants |
|                | and young children.                                 |
|                |                                                     |
|                | To apply the national HIV infant-feeding policy or  |
|                | protocol.                                           |
+----------------+-----------------------------------------------------+
| Duration       | 15 minutes                                          |
+----------------+-----------------------------------------------------+
| Instructions   | -   Identify the national HIV infant-feeding policy |
|                |     or protocol.                                    |
|                |                                                     |
|                | -   Is it clear, is it consistent with              |
|                |     international recommendations, and does it      |
|                |     provide guidance for your healthcare setting?   |
|                |                                                     |
|                | -   Read aloud the following criteria on the        |
|                |     flipchart, whiteboard, or blackboard:           |
|                |                                                     |
|                | ```{=html}                                          |
|                | <!-- -->                                            |
|                | ```                                                 |
|                | -   Acceptable                                      |
|                |                                                     |
|                | -   Feasible                                        |
|                |                                                     |
|                | -   Affordable                                      |
|                |                                                     |
|                | -   Sustainable                                     |
|                |                                                     |
|                | -   Safe                                            |
|                |                                                     |
|                | ```{=html}                                          |
|                | <!-- -->                                            |
|                | ```                                                 |
|                | -   Consider the mothers you have met in your work. |
|                |     Would they be prepared to implement replacement |
|                |     feeding based on the above criteria?            |
|                |                                                     |
|                | -   What other things can you think of that         |
|                |     influence a mother's choice of feeding options? |
|                |     Example: cultural influences                    |
+----------------+-----------------------------------------------------+

Guidance and support for implementing infant-feeding recommendations

-   Provide all mothers who are HIV-positive with counselling that
    includes general information about the advantages and disadvantages
    of various infant-feeding options as well as specific guidance for
    selecting the option most suitable for their situations.

-   Support the mother\'s choice, whichever feeding option she chooses.

-   Conduct local assessments to identify the range of feeding options
    that are acceptable, feasible, affordable, sustainable, and safe in
    particular contexts.

-   Develop information and education about MTCT, including facts about
    transmission through breastfeeding, and target the material to the
    public, affected communities, and families.

-   Train, supervise, and support adequate numbers of people who can
    counsel women who are HIV-positive about infant feeding.

-   Provide updated training to counsellors when new information and
    recommendations emerge.

-   Extend the services of healthcare workers into the community using
    trained lay or peer counsellors.

SESSION 2 Feeding Options During the First 6 Months

Making decisions about infant feeding

Mothers with HIV infection must consider many factors when deciding on a
feeding option that is best for their infants. Healthcare workers play
an important role in guiding their decision-making process by providing
infant-feeding counselling that includes the following:

-   Information about the risk of HIV transmission through breastfeeding

-   Advantages and disadvantages of each available option

-   Respect for local customs, practices, and beliefs when helping a
    mother make infant-feeding choices

Healthcare workers share in the responsibility to protect, promote, and
support safe and appropriate feeding practices. In addition to
supporting women's infant-feeding decisions, referral is needed to
trained infant-feeding counsellors for continued support during the
first two years of a child's growth and development. Programs such as
the Baby Friendly Hospital Initiative have played a vital role in this
important task as well. (See Session 3 HIV Infant-Feeding Counselling
and Support.)

**An HIV-positive pregnant or newly-delivered woman will have to make a
decision among the locally-appropriate options available.**

Replacement feeding during the first 6 months of life

Replacement feeding means feeding infants who are receiving no
breastmilk with a diet that provides most of the nutrients infants need
until the age at which they can be fully fed on family foods. Unlike
breastfeeding, it does not provide immune protection against other
diseases. During the first 6 months of life, replacement feeding should
be with a suitable breast-milk substitute. After six months the suitable
breast-milk substitute should be complemented with other foods.

**If a woman is considering replacement feeding for the first six months
there are two types of breastmilk substitutes: commercial infant formula
or home-modified formula with micronutrient supplements. Cup feeding is
recommended over bottle feeding.** (Refer to Appendix 4-B.)

Option 1: Commercial infant formula

Advantages and disadvantages of using commercial infant formulas are
presented in Table 4.1. Table 4.2 summarises how many tins of commercial
infant formula are required to feed infants each month.

+-----------------------------------------------------------------------+
| Table 4.1 Commercial infant formula                                   |
+-----------------------------------------------------------------------+
| Advantages                                                            |
|                                                                       |
| -   Commercial formula poses no risk of transmitting HIV to the       |
|     infant.                                                           |
|                                                                       |
| -   Commercial formulas are made especially for infants.              |
|                                                                       |
| -   Commercial formula includes most of the nutrients that an infant  |
|     needs.                                                            |
|                                                                       |
| -   Other family members can help feed the infant.                    |
|                                                                       |
| -   If the mother falls ill, others can feed her infant while she     |
|     recovers.                                                         |
|                                                                       |
| **Disadvantages**                                                     |
|                                                                       |
| -   Commercial formula does not contain antibodies, which protect     |
|     infants from infection. An infant who is fed commercial formula   |
|     exclusively is more likely to get diarrhoea and pneumonia and may |
|     develop malnutrition.                                             |
|                                                                       |
| -   A continuous, reliable formula supply is required to prevent      |
|     malnutrition.                                                     |
|                                                                       |
| -   Commercial formula is expensive.                                  |
|                                                                       |
| -   Families need soap for cleaning cups and utensils used in         |
|     preparing the formula.                                            |
|                                                                       |
| -   Safe preparation of commercial formula requires clean water,      |
|     boiled vigorously for 1-2 seconds; this also requires fuel.       |
|                                                                       |
| -   Formula should be made fresh for each feed, according to          |
|     directions, day and night, unless she has access to a             |
|     refrigerator.                                                     |
|                                                                       |
| -   The infant needs to drink from a cup, which may take time to      |
|     learn.                                                            |
|                                                                       |
| -   The mother must stop breastfeeding completely, or she will        |
|     continue to be at risk of transmitting HIV to her infant.         |
|                                                                       |
| -   In some settings, family, neighbours, or friends may question a   |
|     mother who does not breastfeed about her HIV status. (See Session |
|     3 of this module.)                                                |
|                                                                       |
| -   Formula feeding offers the mother no protection from pregnancy.   |
+-----------------------------------------------------------------------+

  ----------------------- --------------------- --------------------------
  Table 4.2 Commercial                          
  infant formula                                
  requirements in first 6                       
  months                                        

  Month                   500 g Tins/Month      450 g Tins/Month

  1                       4                     5

  2                       6                     6

  3                       7                     8

  4                       7                     8

  5                       8                     8

  6                       8                     9

  **Total**               **40**                **44**
  ----------------------- --------------------- --------------------------

Option 2: Home-modified animal milk

Home-modified animal milk is only suitable when commercial formula is
not available. Infants require about 15 litres of modified animal milk
formula per month for the first 6 months. Babies also require
multi-nutrient supplements, in liquid or powder form, to help prevent
anaemia and other forms of malnutrition. Safe preparation and storage of
the home-modified animal milk is also essential for preserving
nutritional value and minimising the risk of malnutrition.

Formula may be prepared at home using fresh animal milks, dried milk
powder, or evaporated milk. Preparing formula with any of these types of
milk involves modifications to make the formula suitable for infants up
to 6 months old. Modifications include diluting the milk with boiled
water in precise amounts to reduce the formula\'s concentration and
adding sugar to increase the formula\'s energy density. The required
dilution amount varies for different animal milks. Dilution is not
required for infants 6 months and older who should also be receiving
complementary foods.

Table 4.3 lists the advantages and disadvantages of using home-modified
infant formulas.

Suitable and unsuitable milks

Not all milks are suitable for use in home-modified infant formula.

The following milks are suitable for home-modified animal milk:

-   Fresh (full-cream or whole) cow, goat, sheep, buffalo, or camel milk

-   Full-cream or whole dried milk powder

-   Evaporated milk

-   Ultra-heat treated (UHT) milk

The following milks and liquids are not suitable for home-modified
animal milk:

-   Fresh animal milk already diluted by an unknown amount

-   Skimmed or low-fat milk powder

-   Sweetened or condensed milk

-   Thin cereal-based gruels

-   Fruit juice, teas, or sodas

**Infants who are fed home-modified animal milk formulas require
micronutrient supplements because animal milks are relatively low in
iron, zinc, vitamin A, vitamin C, and folic acid.**

+-----------------------------------------------------------------------+
| Table 4.3 Home-modified animal milk                                   |
+-----------------------------------------------------------------------+
| **Advantages**                                                        |
|                                                                       |
| -   Home-modified formula presents no risk of HIV transmission.       |
|                                                                       |
| -   Home-modified formula may be less expensive than commercial       |
|     formula and is readily available if the family has milk-producing |
|     animals.                                                          |
|                                                                       |
| -   Mothers and caretakers already using commercial formula can use   |
|     home-modified formula when commercial formula is not available.   |
|                                                                       |
| -   Other family members can help feed the infant.                    |
|                                                                       |
| -   If the mother falls ill, others can feed her infant while she     |
|     recovers.                                                         |
|                                                                       |
| **Disadvantages**                                                     |
|                                                                       |
| -   Home-modified formula does not contain antibodies, which protect  |
|     infants from infection.                                           |
|                                                                       |
| -   An infant who is fed home-modified formula exclusively is more    |
|     likely to get diarrhoea and pneumonia and may become              |
|     malnourished.                                                     |
|                                                                       |
| -   Home-modified formula does not contain all of the nutrients and   |
|     micronutrients that infants need.                                 |
|                                                                       |
| -   Formulas based on animal milks are more difficult for infants to  |
|     digest.                                                           |
|                                                                       |
| -   The mother or caretaker may need to make fresh formula for each   |
|     feeding, day and night, unless she has access to a refrigerator.  |
|                                                                       |
| -   The mother or caretaker must dilute home-modified formula with    |
|     clean water (boiled vigorously for 1--2 seconds) and add sugar in |
|     the correct amount.                                               |
|                                                                       |
| -   The mother must stop breastfeeding completely, or the risk of     |
|     transmitting HIV to her infant will continue.                     |
|                                                                       |
| -   Families will need access to a regular supply of animal milk,     |
|     sugar, multi-nutrient syrup or powder, fuel for boiling water,    |
|     and soap for cleaning feeding cups and utensils used in preparing |
|     the formula.                                                      |
|                                                                       |
| -   Cup feeding is recommended but may take time to learn. (See       |
|     Appendix 4-B.)                                                    |
|                                                                       |
| -   In some settings, a mother who does not breastfeed may be         |
|     questioned about her HIV status by family, neighbours, or         |
|     friends. (See Session 3 of this module.)                          |
|                                                                       |
| -   Formula feeding offers the mother no protection from pregnancy.   |
+-----------------------------------------------------------------------+

Breastmilk feeding options

Mothers who choose to breastfeed should be made aware that:

-   From 5% to 20% of infants breastfed by HIV-positive mothers may
    acquire HIV-infection through breastfeeding.

-   ARV prophylaxis provided during labour and to the infant shortly
    after birth does not provide long-term protection for the infant who
    is breastfeeding.

-   The risk of transmitting HIV to her infant during breastfeeding is
    greater:

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-   When the woman is more ill (by clinical or laboratory measures)

-   When she has mastitis, breast abscess or other similar conditions

-   When the child has ulcers in the mouth

Option 1: Exclusive breastfeeding

Advantages and disadvantages of exclusive breastfeeding are presented in
Table 4.4.

+-----------------------------------------------------------------------+
| Table 4.4 Exclusive breastfeeding                                     |
+-----------------------------------------------------------------------+
| Advantages                                                            |
|                                                                       |
| -   Breastmilk is easily digestible and gives infants all the         |
|     nutrients and water they need. They do not need any other liquid  |
|     or food for the first 6 months.                                   |
|                                                                       |
| -   Breastmilk is always available and does not need any special      |
|     preparation.                                                      |
|                                                                       |
| -   Breastmilk protects infants and children from diseases,           |
|     particularly diarrhoea and pneumonia.                             |
|                                                                       |
| -   Breastfeeding provides the close contact that deepens the         |
|     emotional relationship or bond between mother and child.          |
|                                                                       |
| -   Compared to mixed feeding, exclusive breastfeeding may lower the  |
|     risk of passing HIV.                                              |
|                                                                       |
| -   Breastfeeding reduces mother's risk of some cancers and helps     |
|     space her pregnancies.                                            |
+-----------------------------------------------------------------------+
| Disadvantages                                                         |
|                                                                       |
| -   Risk of MTCT exists as long as the mother who is HIV-infected     |
|     breastfeeds because breastfeeding exposes the infant to HIV.      |
|                                                                       |
| -   The risk of transmitting HIV through breastfeeding is increased   |
|     if the mother has a breast infection (eg, mastitis) or cracked    |
|     and bleeding nipples.                                             |
|                                                                       |
| -   Family, friends, or neighbours may pressure mothers to give       |
|     water, other liquids, or foods to the infant.                     |
|                                                                       |
| -   Although nearly all mothers have sufficient milk to feed their    |
|     infants, some are concerned that they do not have enough milk to  |
|     breastfeed exclusively.                                           |
|                                                                       |
| -   Breastfeeding requires feeding on demand at least 8--10 times per |
|     day.                                                              |
|                                                                       |
| -   Working mothers may need to find a strategy to continue to        |
|     breastfeed exclusively once they return to work, eg privately     |
|     expressing milk during the workday and arranging to store milk in |
|     a cool place.                                                     |
|                                                                       |
| -   Breastfeeding mothers require an additional 500 kcal/day to       |
|     support exclusive breastfeeding during the infant's first 6       |
|     months.                                                           |
+-----------------------------------------------------------------------+

Option 2: *Exclusive breastfeeding with early cessation*

Mothers who are HIV-positive and choose to breastfeed should discontinue
breastfeeding as soon as replacement feeding is acceptable, feasible,
affordable, sustainable, and safe for them and their babies, given local
circumstances, the individual woman's situation, and the risks of
replacement feeding for the infant's age.

Before entering the period of breastfeeding cessation, which may take
from a few days to two weeks, mothers who are HIV-positive should
receive support and guidance to maintain breast health, psychosocial
support, and infant nutritional support.

Advantages and disadvantages of exclusive breastfeeding with early
cessation are presented in Table 4.5.

+-----------------------------------------------------------------------+
| Table 4.5 Exclusive breastfeeding with early cessation                |
+-----------------------------------------------------------------------+
| **Advantages**                                                        |
|                                                                       |
| -   Early cessation of breastfeeding terminates the infant\'s         |
|     exposure to HIV through breastfeeding.                            |
|                                                                       |
| **Disadvantages**                                                     |
|                                                                       |
| -   Infants may become malnourished after breastfeeding stops if      |
|     suitable breastmilk substitutes are unavailable or are provided   |
|     inappropriately.                                                  |
|                                                                       |
| -   Infants may be at increased risk of diarrhoea if breastmilk       |
|     substitutes are not prepared safely.                              |
|                                                                       |
| -   Cup feeding requires caregiver patience and time. If possible,    |
|     mothers should be taught how to feed infants, using a cup and     |
|     expressed breastmilk, before breastfeeding cessation. (See        |
|     Appendix 4-B for a summary of the advantages of cup feeding and   |
|     practical suggestions for cup feeding an infant.)                 |
|                                                                       |
| -   Infants may become anxious and even dehydrated if breastfeeding   |
|     cessation is too rapid.                                           |
|                                                                       |
| -   After six months, a milk source should continue to be given along |
|     with appropriate other foods, see *Appendix 4-C.*                 |
|                                                                       |
| -   Mothers\' breasts may become engorged and infected during the     |
|     transition period if some milk is not expressed and discarded.    |
|                                                                       |
| -   Mothers are at risk of becoming pregnant if they are sexually     |
|     active.                                                           |
|                                                                       |
| -   Early breastfeeding cessation is not recommended for infants who  |
|     are already infected with HIV.                                    |
+-----------------------------------------------------------------------+

Option 3: Wet nursing

Mothers who are HIV-positive, in keeping with local custom, may consider
using a wet nurse as a breastmilk feeding option. It is important that
mothers receive counselling about the potential risk of HIV transmission
from a wet nurse who is HIV-infected or a wet nurse whose HIV status is
unknown. Table 4.6 presents advantages and disadvantages of wet nursing.

+-----------------------------------------------------------------------+
| **Table 4.6 Wet nursing**                                             |
+-----------------------------------------------------------------------+
| **Advantages**                                                        |
|                                                                       |
| -   Use of a wet nurse poses no risk of HIV transmission provided the |
|     wet nurse is not HIV-infected.                                    |
|                                                                       |
| -   Many of the other advantages of breastfeeding described above     |
|     also apply to breastfeeding using a wet nurse.                    |
|                                                                       |
| **Disadvantages**                                                     |
|                                                                       |
| -   The wet nurse must be tested and found to be free of HIV          |
|     infection.                                                        |
|                                                                       |
| -   The wet nurse must protect herself from HIV infection during the  |
|     entire time she is breastfeeding.                                 |
|                                                                       |
| -   The wet nurse must be available to breastfeed the infant          |
|     frequently throughout the day and night, or she must express milk |
|     to be provided when she is away from the infant.                  |
|                                                                       |
| -   People might ask the mother why someone else is breastfeeding her |
|     infant.                                                           |
+-----------------------------------------------------------------------+

*Note:* Additional education and support may be necessary to assist
mothers who choose to use wet nurses. For example, mothers and wet
nurses should be familiar with techniques for breastmilk expression, use
of heat-treated breastmilk, and the option of using breastmilk banks.

Option 4: Expressing and heat-treating breastmilk

Table 4.7 presents advantages and disadvantages of expressing and
heat-treating breastmilk.

+-----------------------------------------------------------------------+
| **Table 4.7 Expressing and heat-treating breastmilk**                 |
+-----------------------------------------------------------------------+
| **Advantages**                                                        |
|                                                                       |
| -   The HIV virus is killed by heating the milk.                      |
|                                                                       |
| -   Breastmilk is the perfect food for babies, and most nutrients     |
|     remain in breastmilk after heating.                               |
|                                                                       |
| -   Breastmilk is always available.                                   |
|                                                                       |
| -   Other responsible family members can help feed the baby.          |
|                                                                       |
| **Disadvantages**                                                     |
|                                                                       |
| -   Although heat-treated breastmilk does not contain HIV, it may not |
|     be as effective as unheated breastmilk in protecting the baby     |
|     from other diseases, but it is still better than formula.         |
|                                                                       |
| -   Expressing and heating breastmilk takes time and must be done     |
|     frequently.                                                       |
|                                                                       |
| -   The baby will need to drink from a cup, and it may take time to   |
|     learn.                                                            |
|                                                                       |
| -   The breastmilk needs to be stored in a cool place and used within |
|     one hour of heating.                                              |
|                                                                       |
| -   Families will need clean water and fuel to wash the baby\'s cup   |
|     and the container used to store the breastmilk.                   |
|                                                                       |
| -   People may wonder why the mother is expressing her milk.          |
+-----------------------------------------------------------------------+

+-----------------+----------------------------------------------------+
| **Exercise 4.2  |                                                    |
| National and    |                                                    |
| local policies  |                                                    |
| on infant       |                                                    |
| feeding:**      |                                                    |
|                 |                                                    |
| **large group   |                                                    |
| discussion**    |                                                    |
+-----------------+----------------------------------------------------+
| Purpose         | To review national policies on feeding options for |
|                 | infants of mothers who are HIV-positive.           |
|                 |                                                    |
|                 | To convey an understanding of the advantages and   |
|                 | disadvantages of feeding options and how to make   |
|                 | each option                                        |
|                 |                                                    |
|                 | safer and healthier for the infant and mother.     |
+-----------------+----------------------------------------------------+
| Duration        | 20 minutes                                         |
+-----------------+----------------------------------------------------+
| Instructions    | -   Review Tables 4.1 to 4.6 in the Participant    |
|                 |     Manual. Share perceptions of the advantages    |
|                 |     and disadvantages of the infant-feeding        |
|                 |     options. Write the responses on the flip       |
|                 |     chart.                                         |
|                 |                                                    |
|                 | -   Review the responses written on the flipchart. |
|                 |                                                    |
|                 | -   Review the barriers to meeting the following   |
|                 |     criteria as discussed in the previous exercise |
|                 |     (Exercise 4.1).                                |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   Acceptable                                     |
|                 |                                                    |
|                 | -   Feasible                                       |
|                 |                                                    |
|                 | -   Affordable                                     |
|                 |                                                    |
|                 | -   Sustainable                                    |
|                 |                                                    |
|                 | -   Safe                                           |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   For each feeding option, share your            |
|                 |     perspective on strategies to minimise the      |
|                 |     barriers to safe infant-feeding practices.     |
|                 |                                                    |
|                 | -   For each feeding option, record on the         |
|                 |     flipchart the strategies for minimising the    |
|                 |     barriers to safe infant-feeding practices.     |
+-----------------+----------------------------------------------------+

SESSION 3 Infant-Feeding Counselling and Support

Counselling about infant feeding

A woman who is HIV-positive should receive counselling that includes:

-   Information about the risk of HIV transmission through breastfeeding

-   Information about the advantages and disadvantages of various
    infant-feeding options

-   Guidance in selecting and adhering to the option most suitable for
    her situation

-   Respect for local customs, practices, and beliefs when presenting
    infant-feeding choices

How to prepare non-breastfeeding women for questions

In many cultures, women are expected to breastfeed their infants for one
year or longer. If the infant is not breastfed or if breastfeeding is
discontinued early, questions about the mother\'s HIV status may arise.
Once a woman decides how she plans to feed her infant, ideally during
the antenatal period, the healthcare worker should help her prepare to
answer questions about her choice.

During the counselling process, healthcare workers should ask women
specific questions, such as "What will you say when your mother-in-law
or neighbour asks you why you are not breastfeeding or why you have
stopped breastfeeding?" or "What will you tell your husband when he
tells you to give the baby porridge when you have chosen to breastfeed
exclusively?" The healthcare worker may help the mother prepare to
answer these questions. The counselling session may also be an
opportunity to further discuss issues that relate to disclosure of the
mother\'s HIV status to the family.

As PMTCT programmes expand, community education and mobilization
activities should be developed to help women undertake the choice of not
breastfeeding or stopping breastfeeding early. They should also be aimed
at helping mothers who choose to exclusively breastfeed to maintain that
choice.

For information on stigma related to replacement feeding or early
cessation of breastfeeding, see *Module 5: Stigma and Discrimination
Related to MTCT.*

The final decision about her infant-feeding strategy should be the
woman\'s, and she must receive support for her choice.

> **Additional training in infant-feeding counselling and support**

Infant-feeding counselling for women who are HIV-positive is an integral
part of every PMTCT programme and requires that counsellors have many
specific skills. Special WHO training courses exist about general
breastfeeding and infant-feeding counselling and support (a 40-hour
course) and for HIV and infant-feeding counselling (a 3-day course).
Healthcare workers who are expected to provide infant-feeding
counselling should have this type of training. Specific infant-feeding
counselling skills include listening and learning, building the
client\'s confidence, giving support, and providing information.

Infant-feeding counselling, education, and support is

-   Provided during both the antenatal and postnatal periods.

-   Based on country or local guidelines and includes an understanding
    of the sustainable resources accessible to the mother and her
    family.

-   Based on the individual woman\'s circumstances, including her
    health, social, and financial status as well as her customs and
    beliefs.

Infant-feeding counselling, education, and support also

-   Includes information on various feeding options, including the
    advantages and disadvantages of each.

-   Provides women with the skills needed to feed their infants safely.

-   Includes demonstrations and/or opportunities for practice.

-   Encourages partner or family involvement in infant-feeding
    decisions.

-   Supports women when they disclose their HIV status to loved ones.

Counselling visits

Mothers who are HIV-positive should receive infant-feeding counselling
over the course of several sessions. At least one counselling session
should take place during the antenatal period. If possible, do this
sometime after post-test counselling, but not immediately after the
mother learns her test results.

The counsellor should visit the mother and infant immediately after the
birth and schedule another visit within 7 days to monitor postpartum and
infant-feeding progress.

It is advisable to schedule monthly follow-up sessions whenever the
mother brings the child to the clinic for well-baby checkups or
immunisations. Additional sessions may be required during special
high-risk periods, such as when the:

-   Child is sick

-   Mother returns to work

-   Mother decides to change feeding methods

Infant-feeding counselling steps for women who are HIV-infected

The flowchart in Figure 4.1 illustrates the six steps for counselling
mothers infected with HIV about infant feeding. Use the flowchart on the
next page as follows:

+-----------------------------------------------------------------------+
| 1.  If this is the mother\'s first infant-feeding counselling session |
|     and...                                                            |
+-----------------------------------------------------------------------+
| She is early in her pregnancy:                                        |
|                                                                       |
| -   Do Steps 1--4.                                                    |
|                                                                       |
| -   Ask her to return in her third trimester to learn how to          |
|     implement\                                                        |
|     the feeding method (Step 5).                                      |
|                                                                       |
|     *She is late in her pregnancy:*                                   |
|                                                                       |
| -   Do Steps 1--5.                                                    |
|                                                                       |
| She already has a child and is breastfeeding or mixed feeding:        |
|                                                                       |
| -   Do relevant parts of Steps 1--5.                                  |
|                                                                       |
| She already has a child and is using only replacement feeding:        |
|                                                                       |
| -   Do relevant parts of Step 5 and Step 6.                           |
+-----------------------------------------------------------------------+
| 2.  If the mother has already been counselled and chosen a feeding    |
|     option and...                                                     |
+-----------------------------------------------------------------------+
| *She is still pregnant or newly delivered, but has not yet been       |
| counselled on how to succeed in her selected feeding method:*         |
|                                                                       |
| -   Begin with relevant parts of Step 5.                              |
|                                                                       |
|     *If she already has a child:*                                     |
|                                                                       |
| -   Begin with Step 6.                                                |
+-----------------------------------------------------------------------+
| 3.  If this is a follow-up visit...                                   |
+-----------------------------------------------------------------------+
| -   Begin with Step 6.                                                |
+-----------------------------------------------------------------------+

Postnatal visits

During each postnatal visit, clinic staff should review information from
the infant-feeding counselling session and focus on issues most relevant
to the mother. Reinforcing essential and relevant information supports
optimal infant nutrition, growth, and development while minimising
risks.

+-----------------+----------------------------------------------------+
| Exercise 4.3    |                                                    |
| Infant-feeding  |                                                    |
| counselling and |                                                    |
| support: role   |                                                    |
| play            |                                                    |
+-----------------+----------------------------------------------------+
| Purpose         | To provide information on issues that may arise    |
|                 | when counselling for infant feeding.               |
+-----------------+----------------------------------------------------+
| Duration        | 70 minutes                                         |
+-----------------+----------------------------------------------------+
| Instructions    | -   Join with one other person as requested by     |
|                 |     facilitator and review the "Infant-feeding     |
|                 |     counselling for women who are HIV-positive"    |
|                 |     flowchart in Figure 4.1.                       |
|                 |                                                    |
|                 | -   Decide which member of your pair will play the |
|                 |     role of the infant-feeding counsellor and      |
|                 |     which will play the role of the mother.        |
|                 |                                                    |
|                 | -   The participant who will play the role of the  |
|                 |     mother will meet with the facilitator in a     |
|                 |     separate section of the training room to       |
|                 |     receive the role-play scenario.                |
|                 |                                                    |
|                 | -   The "mothers" will then introduce themselves   |
|                 |     to the "infant-feeding counsellors" while the  |
|                 |     latter will take the lead in following the     |
|                 |     flowchart steps.                               |
|                 |                                                    |
|                 | -   Change roles to repeat the role-play as        |
|                 |     requested by the facilitator.                  |
|                 |                                                    |
|                 | -   After 30 minutes, join the entire group and    |
|                 |     share your experiences by answering the        |
|                 |     following questions:                           |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   "Infant-feeding counsellors"                   |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   Were there difficulties with any of the steps? |
|                 |                                                    |
|                 | -   Which steps were most troublesome?             |
|                 |                                                    |
|                 | -   What can you do to become more competent in    |
|                 |     providing infant-feeding support?              |
|                 |                                                    |
|                 | -   Did you feel that you had the skills to work   |
|                 |     with a "mother" who was fearful, anxious, or   |
|                 |     upset about her own or her child's welfare?    |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   "Mothers"                                      |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   What were the main points you learned in the   |
|                 |     session?                                       |
|                 |                                                    |
|                 | -   How has the session changed the way you would  |
|                 |     feed your infant?                              |
|                 |                                                    |
|                 | -   If you will not make any changes, why not?     |
|                 |                                                    |
|                 | -   What issues came up in the counselling session |
|                 |     that no one anticipated?                       |
|                 |                                                    |
|                 | -   How would you have liked to address those      |
|                 |     issues?                                        |
+-----------------+----------------------------------------------------+

Module 4: Key Points

-   All women who are HIV-positive need infant-feeding counselling and
    support.

-   HIV transmission risk continues the entire time a mother who is
    HIV-infected breastfeeds her child.

-   The mother has the right to choose how she wants to feed her infant;
    the healthcare worker\'s job is to support her choice.

-   Mothers who are HIV-positive should avoid breastfeeding when
    replacement feeding is acceptable, feasible, affordable,
    sustainable, and safe.

-   Exclusive breastfeeding and early breastfeeding cessation are
    appropriate when breastfeeding is the chosen option.

-   Counselling, education, and support are key to establishing and
    maintaining safer infant-feeding practices.

-   Postnatal counselling and infant follow-up are required throughout
    the first 2 years of the infant\'s life.

-   PMTCT staff can prevent spillover or misuse of replacement feeding
    in three ways:

```{=html}
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```
-   Promote exclusive breastfeeding for the general population

-   Discourage use of replacement milk supplies by mothers whose infants
    do not need them

-   Respect the International Code of Marketing of Breast Milk
    Substitutes

APPENDIX 4-A United Nations infant-feeding recommendations for mothers
who are HIV-infected

UN infant-feeding recommendations (2001) for mothers who are
HIV-infected are as follows:

-   When replacement feeding is acceptable, feasible, affordable,
    sustainable, and safe (terms defined in Session 1), avoidance of all
    breastfeeding by HIV-infected mothers is recommended.

-   Otherwise, exclusive breastfeeding is recommended during the first
    months of life.

-   To minimise HIV transmission risk, HIV-positive mothers should
    discontinue breastfeeding as soon as feasible, taking into account
    local circumstances, the individual woman\'s situation, and the
    risks of replacement feeding (which include malnutrition and
    infections other than HIV).

-   The UN suggests early cessation of breastfeeding with safe
    transition (over a period of a few days or up to 2 weeks),
    recognising that this is difficult and that the mother and infant
    will require support.

-   When HIV-positive mothers choose not to breastfeed from birth or
    stop breastfeeding later, counsellors or healthcare workers should
    provide them with specific guidance and support for at least the
    first 2 years of the child\'s life to ensure adequate replacement
    feeding.

-   Programmes should make replacement feeding safer for HIV-positive
    mothers and families.

-   All HIV-infected mothers should receive counselling, which includes
    promotion of general information about the risks and benefits of
    various infant feeding options, and specific guidance in selecting
    the option most likely to be suitable for their situation.

-   Whatever a mother decides, she should be supported in her choice.

This appendix was adapted from the following:

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for
    decision-makers,* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for health
    care managers and supervisors.* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_MS.pdf

APPENDIX 4-B Advantages of cup feeding

*Breastmilk substitutes should be given from a cup.*

Healthcare workers should explain to mothers and families that cup
feeding is preferable for the following reasons:

-   Cups are safer, as they are easier to clean with soap and water than
    bottles.

-   Cups are less likely than bottles to be carried around for a long
    time (which gives bacteria the opportunity to multiply).

-   Cup feeding requires the mother or other caregiver to hold and have
    more contact with the infant and provides more psychosocial
    stimulation than bottle feeding.

-   Cup feeding is better than feeding with a cup and spoon because
    spoon feeding takes longer and the mother may stop before the infant
    has had enough. However, some caregivers prefer to use a cup and
    spoon.

*Feeding bottles are not necessary and for most purposes they are not
the preferred option.*

Using feeding bottles and artificial teats should be actively
discouraged because:

-   Bottle feeding increases the infant\'s risk of diarrhoea, dental
    disease, and ear infections.

-   Bottle feeding increases the risk that the infant will receive
    inadequate stimulation and attention during feedings.

-   Bottles and teats need to be thoroughly cleaned with a brush and
    then boiled for sterilisation; this takes time and fuel.

-   Bottles and teats cost more than cups and are less readily
    available.

*Healthcare workers should receive training to show mothers and families
how to cup feed.*

> How to feed an infant with a cup

-   Hold the infant sitting upright or semi-upright on your lap.

-   Hold the cup of milk to the infant\'s lips.

-   Tip the cup so that the milk just reaches the infant\'s lips and it
    rests lightly on the infant\'s lower lip.

-   The infant will become alert and open its mouth and eyes.\*

-   **Do not pour** the milk into the infant\'s mouth. Hold the cup to
    the infant\'s lips and let the infant take it.

-   When the infant has had enough, he/she will close its mouth and take
    in no more milk.

-   Measure the infant\'s intake at each feeding over 24 hours.

\*Low-birthweight infants will start to take milk with the tongue. A
full-term or older infant will suck the milk, spilling some.

This appendix was adapted from the following:

-   WHO, UNICEF and USAID. 2004. *HIV and infant feeding counselling
    tools*. Currently in print, to be available in late 2004 from
    http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for
    decision-makers,* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for health
    care managers and supervisors.* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_MS.pdf

APPENDIX 4-C Feeding from 6--24 months

All infants, including infants who continue to be breastfed, require
nutritious foods beginning at about 6 months of age. The term
*complementary food* refers to any food, whether manufactured or locally
prepared, suitable as a complement to breastmilk or a breastmilk
substitute. This term is preferred because it implies that the newly
introduced foods are provided in addition to the milk feeds; they are
*not* intended to replace milk at this point. Replacement feeding
describes the use of alternative foods when there is no breastfeeding,
such as a commercial or home-modified breastmilk substitute.

*Infants should receive continued frequent breastfeeding or cup feeding
with commercial infant formula or other milk into the second year of
life.*

Recommendations for complementary feeding should be based on locally
available foods and feeding practices. General principles for
complementary feeding include the following:

Introducing complementary foods

-   Begin introducing complementary foods in small amounts at 6 months
    of age. The amount of food required will increase as the child gets
    older. (See table on the following page.)

-   After complementary foods have been introduced, the infant will
    continue to need breastmilk or milk in some form frequently
    throughout the day.

-   For infants who are not breastfed, animal milk requirements after 6
    months are about 1 to 2 cups per day.

-   Infants older than 6 months do not require dilution of animal milks.
    However, fresh animal\'s milk should still be boiled.

-   No special preparation is needed for processed, pasteurised, or
    ultra-heat treated (UHT) milk. However, the mother or caregiver
    should increase the number of complementary feedings as the child
    gets older. The appropriate number of feedings depends on the energy
    density of the local foods and the usual amounts consumed at each
    feeding. When no milk is available, the diet should include other
    animal-source foods and/or enriched foods.

-   The table on the next page shows the type, frequency, and amounts of
    complementary foods that the average healthy infant requires at
    different ages. If the energy density or the amount of food per meal
    is low, more frequent feedings may be required.

-   Energy requirements are higher for unhealthy infants because of the
    metabolic effects of infections. Energy requirements also are higher
    for infants who are severely malnourished and undergoing nutritional
    rehabilitation.

-   Gradually increase food consistency and the variety of foods offered
    as the infant gets older, adapting to the infant\'s nutritional
    requirements and physical abilities.

APPENDIX 4-C Feeding from 6--24 months *(continued)*

+----------+---------------------+---------------------+-------------+
| **Age**  | **Texture**         | **Frequency**       | **Amount at |
|          |                     |                     | each        |
|          |                     |                     | meal\***    |
+----------+---------------------+---------------------+-------------+
| 6 months | Soft porridge;      | 2 times a day plus  | 2--3        |
|          | well-mashed         | frequent milk feeds | tablespoons |
|          | vegetable, meat, or |                     |             |
|          | fruit               |                     |             |
+----------+---------------------+---------------------+-------------+
| 7--8     | Mashed foods        | 3 times a day plus  | 2/3 cup^+^  |
| months   |                     | frequent milk feeds |             |
+----------+---------------------+---------------------+-------------+
| 9--11    | Finely chopped or   | 3 meals plus 1      | 2/3 cup^+^  |
| months   | mashed foods, and   | snack between meals |             |
|          | foods that baby can | plus milk feeds     |             |
|          | pick up             |                     |             |
+----------+---------------------+---------------------+-------------+
| 12--24   | Family foods,       | 3 meals plus 2      | 1 full      |
| months   | chopped or mashed   | snacks between      | cup^+^      |
|          | if necessary        | meals plus milk     |             |
|          |                     | feeds               |             |
+----------+---------------------+---------------------+-------------+
| If baby  |                     |                     |             |
| is not   |                     |                     |             |
| br       |                     |                     |             |
| eastfed, |                     |                     |             |
| give in  |                     |                     |             |
| a        |                     |                     |             |
| ddition: |                     |                     |             |
| 1-2 cups |                     |                     |             |
| of milk  |                     |                     |             |
| per day, |                     |                     |             |
| and 1-2  |                     |                     |             |
| extra    |                     |                     |             |
| meals    |                     |                     |             |
| per day. |                     |                     |             |
+----------+---------------------+---------------------+-------------+
| **\***   |                     |                     |             |
| This     |                     |                     |             |
| chart    |                     |                     |             |
| should   |                     |                     |             |
| be       |                     |                     |             |
| adapted  |                     |                     |             |
| to the   |                     |                     |             |
| local    |                     |                     |             |
| context, |                     |                     |             |
| using    |                     |                     |             |
| local    |                     |                     |             |
| utensils |                     |                     |             |
| to show  |                     |                     |             |
| the      |                     |                     |             |
| amount.  |                     |                     |             |
|          |                     |                     |             |
| ^+^ One  |                     |                     |             |
| cup =    |                     |                     |             |
| 250 ml   |                     |                     |             |
+----------+---------------------+---------------------+-------------+

-   Offer children 6 months and older an increasing variety of
    nutrient-dense foods. On a daily basis, or as often as possible,
    they should eat animal foods such as meat, poultry, fish, eggs,
    dairy products, or other adequate local sources of protein. Children
    should also eat fruit and vegetables that are rich in vitamin A
    daily. Satisfying the nutritional needs of children in this age
    group through a vegetarian diet is difficult.

-   If nutritionally adequate complementary foods or fortified
    complementary foods are not available locally, consider giving the
    child a vitamin-mineral supplement to avoid growth and development
    deficiencies.

-   Mothers and caregivers should avoid giving drinks with low nutrient
    value, such as tea and coffee (which interfere with iron absorption)
    and sugary drinks such as soda. The amount of juice offered should
    be limited to avoid displacing more nutrient-rich foods.

-   Avoid offering foods that may cause choking, such as those that have
    a shape or consistency that could cause the food to become lodged in
    the trachea. Foods to avoid include nuts, grapes, and raw carrots.

Responsive feeding

-   Feed infants directly and assist older children when they feed
    themselves, being sensitive to when the infant or child is hungry or
    full.

-   Feed slowly and patiently, encouraging the child to eat, but *do
    not* force food.

-   Encourage food intake by experimenting with different food
    combinations, tastes, and textures, especially if the child refuses
    to eat.

-   Minimise distractions during meals if the child loses interest
    easily.

-   Remember that feeding times are periods of learning and love: talk
    to children during feeding, using eye-to-eye contact.

APPENDIX 4-C Feeding from 6--24 months *(continued)*

Good hygiene and proper food handling

-   Wash hands before food preparation and eating.

-   Store foods safely and serve foods immediately after preparation.

-   Use clean utensils to prepare and serve food.

-   Use clean cups and bowls to feed children.

-   Avoid using feeding bottles, which are difficult to keep clean.

Feeding children with allergies and illnesses

Mothers and caregivers of infants and young children with a family
history of allergies or food sensitivities should delay introducing
cow\'s milk, egg whites, and fish until after the infant reaches 12
months of age, and should not feed the child peanuts or other nuts until
after the child is 3 years old.

When the child's age permits, mothers and caregivers should give the
child increased amounts of fluids when they are ill, and encourage them
to eat semisolid or solid foods. After the illness, mothers and
caregivers should offer their children at least one extra meal a day and
encourage them to eat more.

This appendix was adapted from the following:

-   WHO, UNICEF and USAID. 2004. *HIV and infant feeding counselling
    tools*. Currently in print, to be available in late 2004 from
    http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for
    decision-makers,* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf

-   WHO and UNAIDS. 2003. *HIV and infant feeding: Guidelines for health
    care managers and supervisors.* Retrieved 30 July 2004, from
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_MS.pdf