IS BREAST STILL BEST?

By Susan Gerhard

Mothering Sept./Oct. 2001

Doctors in the US and other industrialized countries have been unwavering in one piece of advice to HIV-positive mothers: no breastfeeding. But new research brings up pivotal questions about their logic.

Researcher Anna Coutsoudis startled her colleagues at the 13th International AIDS Conference in Durban, South Africa, with the information that she presented. In a study of 551 mother-and-child pairs, first published in the prestigious peer-reviewed journal The Lancet (August 7, 1999), her group found that mothers who breastfed their babies for at least three months had no more chance of transmitting HIV to their children than mothers who never breastfed at all. Even more surprising, children who received a mixed diet of formula and breastmilk had the highest HIV rates over a period of six months. Coutsoudis followed these children for more than 15 months, and the results remained the same.(1)

Unfortunately, so did the old "no-breastfeeding" guidelines, particularly in the industrialized world where mainstream doctors consider formula a safe option for children. "I promise you that this disagreement about breastfeeding will be on the front pages of newspapers all over the world tomorrow," Steve Thomas of the University of Pennsylvania told an audience at the Durban conference. Actually, the US media greeted the news with a resounding silence. Unlike the AZT study ACTG 076, which was halted early so that children in the placebo wing would no longer be prevented from getting a drug deemed effective, this study's exciting results haven't inspired doctors to advise women to breastfeed -- the oldest known form of immune-system enhancement for children.

Marian Tompson, one of the founders of La Leche League, has been following the issue closely and, independently of the organization, is compiling a database of HIV-positive mothers who are breastfeeding their children. Over the past four decades, Tompson has seen mothers through many challenges to their right to feed their children, from fears of PCBs in breastmilk to the idea that women could give their children a breast cancer virus through nursing. In each case, when the issue was examined closely, the benefits of breastfeeding outweighed any potential for harm. "What's interesting," Tompson said, "is how many of the big health agencies were so quick to jump on AZT or nevirapine after short trials but are loathe to try out exclusive breastfeeding." (2)

In developed countries, women with conditions ranging from hepatitis A and B to tuberculosis (inactive) are advised to breastfeed their infants. (3) That's because, as the American Academy of Pediatrics pointed out in a 1997 policy statement, even among middle-class populations in the US, Canada, and Europe, artificially-fed children have much greater risks of death; (4) one study estimated that such children had 14 times as many hospitalizations.(5) The only absolute disease-related contraindications to breastfeeding are HIV-positive status, active untreated tuberculosis, and a rare disease called galactosemia.(6)

In less-developed countries, where campaigns to eradicate the exploitative marketing of formula have made headway, HIV-in-breastmilk scares are undoing years of good work. In the early 1990s, the United Nations Program on HIV/AIDS, the World Health Organization, and the UN Children's Fund collaborated on guidelines that advised women with HIV to continue breastfeeding. But by 1998, they'd announced a different project called New Initiatives to Reduce HIV Transmissions from Mother-to Child in Low-Income Countries, which aimed to provide HIV-positive women with what they considered "safe" infant feeding methods, i.e., formula.(7)

Despite the agencies' stated intent to help HIV-positive mothers make "informed" choices about breastfeeding, says George Kent, coordinator of the Task Force on Children's Nutrition Rights for the World Alliance on Nutrition and Human Rights, "their persistent expression of alarm over the risk of virus transmission tends to lead health workers and mothers to only one conclusion: HIV-positive mothers should not breastfeed."(8)

The agencies aren't the only ones sounding the alarm. A Kenyan study published in The Lancet claims that HIV-positive mothers risk dying from "depletion" through breastfeeding. However, Coutsoudis counters that her own study finds no increased mortality among breastfeeding women, and writes that there is not enough weight loss in the Kenyan study to explain the deaths.(9,10) In the same issue of The Lancet, another researcher writes, "Although breastfeeding may affect maternal nutritional status, it is not known to kill mothers. During acute famine, breastfeeding women generally do well, with no increased mortality."(11)

But just how dangerous is formula feeding? a WHO-pooled analysis of 1980s data found that, in poorer countries, "infants who are not breastfed have a six-fold greater risk of dying from infectious diseases in the first two months of life than those who are breastfed."(12)

Ted Greiner, an international breastfeeding consultant with the Uppsala (Sweden) University Medical School, is not pleased with the lack of impact the Coutsoudis study has had on the WHO/UNAIDS/UNICEF health policy. "They often mention it," he told me, "but then shed crocodile tears over the low prevalence of exclusive breastfeeding and say it thus has little implications for their policy -- implying, amazingly, that it is easier to convince African mothers not to breastfeed at all than to do so exclusively."(13)

The scientific literature varies on the possible risk of transmitting HIV during breastfeeding, from 5 percent to 29 percent. UNAIDS itself suggests that the risk of infection from breastfeeding is around 15 percent, which means that 85 percent of infants born to HIV-positive mothers are not infected through breastfeeding.(14) The Kenyan study found a 16.2 percent transmission rate through breastfeeding, but Coutsoudis argues that the most important finding of the study was that, after two years, mortality for both formula-fed and breastfed babies was similar. "The most important conclusion," she writes, "is that the lower rate of HIV-1 transmission achieved by avoiding breastfeeding is almost completely negated by the increased mortality among the formula-fed infants."(15,16)

Other breastfeeding advocates believe the real research is yet to be done. According to Kent, "Research is needed not simply on virus transmission but on health outcomes."(17)

So far there has been little information on the overall health of either formula-fed or breastfed children of HIV-positive mothers. In 1990, Italian researchers found that HIV-positive breastfed children remained asymptomatic twice as long as their formula-fed counterparts,(18) yet another indication that for infants of HIV-positive women, breastfeeding may be just the opposite of a "high-risk" behavior.

In the US, where the fear of formula is extremely low (70 percent of American children receive commercial milk preparations as their primary source of nutrition during the first year),(19) breastfeeding by HIV-positive mothers remains taboo and, in at least one case, illegal. HIV-positive Kathleen Tyson, whose milk tested negative for HIV, had her newborn taken out of her legal custody in 1998 because she threatened to breastfeed him. Will the courts now view such cases in a new light?

Notes

1. Anna Coutsoudis et al., "Method of Feeding and Transmission of HIV-1 from Mothers to Children by 15 Months of Age: Prospective Cohort Study from Durban, South Africa," AIDS 15 (2001): 379-387.

2. Personal interviews.

3. Robert M Lawrence, quoted in Nancy Walsh's "Breast-feeding OK Even with Maternal Infection," Pediatric News (August 2000): 9.

4. American Academy of Pediatrics, "Breastfeeding and the Use of Human Milk," Pediatrics 100, no. 6 (1997): 1035-1039.

5. M. Walker, "A Fresh Look at the Risks of Artificial Infant Feeding," Journal of Human Lactation 9, no. 2 (1993): 97-107.

6. See Note 3.

7. George Kent, "HIV/AIDS, Infant Nutrition, and Human Rights," unpublished paper, (September 2000).

8. Ibid.

9. Ruth Nduati et al., "Effect of Breastfeeding on Mortality among HIV-1 Infected Women: A Randomised Trial," The Lancet 357 (2001): 1651-1655.

10. Anna Coutsoudis, "Are HIV-Infected Women Who Breastfeed at Increased Risk of Mortality?" AIDS 15, no. 5: 653-655.

11. Marie-Louise Newell, "Does Breastfeeding Really Affect Mortality among HIV-1 Infected Women?" The Lancet 357 (May 26, 2001).

12. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality, "Effect of Breastfeeding on Infant and Child Mortality Due to Infectious Diseases in Less Developed Countries: A Pooled Analysis," The Lancet 355 (February 5, 2000).

13. Personal interview.

14. UNAIDS/UNICEF/WHO, "HIV and Infant Feeding: A Guide for Health Care Managers and Supervisors" (1998), quoted in Pamela Morrison's "HIV and Infant Feeding: To Breastfeed or Not to Breastfeed: The Dilemma of Competing Risks," Breastfeeding Review 7, no. 2 (1999): 5-13.

15. R. Nduati et al., "Effect of Breastfeeding and Formula Feeding on Transmission of HIV-1," Journal of American Medical Association 283, no. 9 (2000): 1167-1174.

16. Anna Coutsoudis, letter, Journal of the American Medical Association 284, no. 8 (August 23/30, 2000).

17. Personal interview.

18. A. E. Tozzi et al., "Does Breastfeeding Delay Progression to AIDS in HIV-Infected Children?" AIDS 4 (1990): 1493-1494.

19. Marc Kaufman, "What's in Infant Formula?", Washington Post, June 1, 1990. See also A. Ryan, "The Resurgence of Breastfeeding in the United States," Pediatrics 99, no. 4 (April 1997).