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1.  Inadequate: A Metaphor for the Lives of Low-Income Women? 
Breastfeeding Medicine  2009;4(Suppl 1):S-41-S-43.
Abstract
Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most U.S. women. This article analyzes the term “inadequate” not just as self-description of a woman's milk supply, but also as a metaphor for the lives of low-income women in the United States, the group least likely to breastfeed. Low-income women in the United States not only have inadequate incomes as compared to the general population, but inadequate child care, education, preventive health services, inadequate lifespans, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding.
doi:10.1089/bfm.2009.0035
PMCID: PMC2763322  PMID: 19827922
2.  High initiation and long duration of breastfeeding despite absence of early skin-to-skin contact in Karen refugees on the Thai-Myanmar border: a mixed methods study 
Background
Early skin-to-skin contact (SSC) after birth is recommended as part of the United Nations Children’s Fund (UNICEF) baby friendly health initiative to promote optimum breastfeeding. This paper reports rates of breastfeeding initiation and duration in a low resource environment, where early SSC is not practised, and explores views of pregnant women and midwives surrounding breastfeeding and swaddling.
Methods
Data from records from a single hospital on the Thai-Myanmar border where refugee women gave birth during a one-year period (2010) were used to determine breastfeeding initiation rates and the time of the first breastfeed, and duration of breastfeeding of the previous alive child in multigravidae. Focus group discussions (FGD) were conducted to obtain information from pregnant women attending antenatal care about their intended or previous duration of breastfeeding and views on breastfeeding. Interviews with local midwives explored reasons for high rates of breastfeeding in this setting and the practice of newborn swaddling.
Results
Of 1404 live births in 2010 in Maela refugee camp there were 982 evaluable mother-newborn pairs, including 80 infants born before 37 weeks gestation. Initiation of breastfeeding within the first hour after birth and exclusive breastfeeding at discharge in term mother-newborn pairs was 91.2% (823/902) and 99.3% (896/902); and before 37 weeks gestation, 48.8% (39/80) and 98.8% (79/80). Reported duration of previous breastfeeding was 19 (range 2 to 72) months.
During FGD all primigravidae (n = 17) intended to breastfeed and all multigravidae (n = 33) had previously breastfed; expected or previous duration of feeding was for more than one year or longer. The major theme identified during FGD was breastfeeding is “good”. Women stated their intention to breastfeed with certainty. This certainty was echoed during the interviews with midwifery staff. SSC requires a delay in early swaddling that in Karen people, with animistic beliefs, could risk loss of the spirit of the newborn or attract malevolent spirits.
Conclusions
In a population with a strong culture of breastfeeding and robust breastfeeding practices, high rates of initiation and duration of breastfeeding were found despite a lack of early skin-to-skin contact. Local preferences, traditions and practices that protect, support and maintain high rates of breastfeeding should be promoted.
doi:10.1186/1746-4358-7-19
PMCID: PMC3547777  PMID: 23241099
Breastfeeding initiation; Breastfeeding duration; Early skin-to-skin care; Midwifery; Refugee; Resource-poor; Swaddling
3.  Factors affecting intention to breastfeed among Syrian and Jordanian mothers: a comparative cross-sectional study 
Background
Breastfeeding is considered the ideal method of infant feeding for at least the first six months of life. This study aimed to compare breastfeeding intention between Syrian and Jordanian women and determine factors associated with breastfeeding intention among pregnant women in these two countries.
Methods
A cross-sectional design was used to collect data from1200 pregnant women aged 18 years and above (600 participants from each country). A self- administered questionnaire was used to collect data on socio-demographic characteristics and breastfeeding intention.
Results
Intention to breastfeed was reported by 77.2% of Syrian and 76.2% of Jordanian pregnant women. There was no significant difference in intention to breastfeed between Syrian women and Jordanian women. In both countries, women with a more positive attitude to breastfeeding, women with previous breastfeeding experience and women with supportive partners were more likely to intend to breastfeed. Syrian women with a monthly family income of more than US$200, younger than 25 and primiparous or having one child were more likely to report an intention to breastfeed their infants. Jordanian women with an education level of less than high school and not living with their family-in-law were more likely to intend to breastfeed.
Conclusions
In Syria and Jordan, a more positive attitude to breastfeeding, previous breastfeeding experience and presence of supportive husbands are associated with intention to breastfeed. These factors should be considered when planning programs designed to promote breastfeeding in these two countries.
doi:10.1186/1746-4358-5-6
PMCID: PMC2907311  PMID: 20598137
4.  Ringing Up about Breastfeeding: a randomised controlled trial exploring early telephone peer support for breastfeeding (RUBY) – trial protocol 
Background
The risks of not breastfeeding for mother and infant are well established, yet in Australia, although most women initiate breastfeeding many discontinue breastfeeding altogether and few women exclusively breastfeed to six months as recommended by the World Health Organization and Australian health authorities. We aim to determine whether proactive telephone peer support during the postnatal period increases the proportion of infants who are breastfed at six months, replicating a trial previously found to be effective in Canada.
Design/Methods
A two arm randomised controlled trial will be conducted, recruiting primiparous women who have recently given birth to a live baby, are proficient in English and are breastfeeding or intending to breastfeed. Women will be recruited in the postnatal wards of three hospitals in Melbourne, Australia and will be randomised to peer support or to ‘usual’ care. All women recruited to the trial will receive usual hospital postnatal care and infant feeding support. For the intervention group, peers will make two telephone calls within the first ten days postpartum, then weekly telephone calls until week twelve, with continued contact until six months postpartum. Primary aim: to determine whether postnatal telephone peer support increases the proportion of infants who are breastfed for at least six months. Hypothesis: that telephone peer support in the postnatal period will increase the proportion of infants receiving any breast milk at six months by 10% compared with usual care (from 46% to 56%).
Outcome data will be analysed by intention to treat. A supplementary multivariate analysis will be undertaken if there are any baseline differences in the characteristics of women in the two groups which might be associated with the primary outcomes.
Discussion
The costs and health burdens of not breastfeeding fall disproportionately and increasingly on disadvantaged groups. We have therefore deliberately chosen trial sites which have a high proportion of women from disadvantaged backgrounds. This will be the first Australian randomised controlled trial to test the effectiveness and cost effectiveness of proactive peer telephone support for breastfeeding.
Trial registration
Australian and New Zealand Clinical Trials Registry ACTRN12612001024831.
doi:10.1186/1471-2393-14-177
PMCID: PMC4068322  PMID: 24886264
Breastfeeding; Exclusive breastfeeding; Breastfeeding rates; Peer support; Telephone; Australia
5.  Pregnancy and Infant Outcomes among HIV-Infected Women Taking Long-Term ART with and without Tenofovir in the DART Trial 
PLoS Medicine  2012;9(5):e1001217.
Diana Gibb and colleagues investigate the effect of in utero tenofovir exposure by analyzing the pregnancy and infant outcomes of HIV-infected women enrolled in the DART trial.
Background
Few data have described long-term outcomes for infants born to HIV-infected African women taking antiretroviral therapy (ART) in pregnancy. This is particularly true for World Health Organization (WHO)–recommended tenofovir-containing first-line regimens, which are increasingly used and known to cause renal and bone toxicities; concerns have been raised about potential toxicity in babies due to in utero tenofovir exposure.
Methods and Findings
Pregnancy outcome and maternal/infant ART were collected in Ugandan/Zimbabwean HIV-infected women initiating ART during The Development of AntiRetroviral Therapy in Africa (DART) trial, which compared routine laboratory monitoring (CD4; toxicity) versus clinically driven monitoring. Women were followed 15 January 2003 to 28 September 2009. Infant feeding, clinical status, and biochemistry/haematology results were collected in a separate infant study. Effect of in utero ART exposure on infant growth was analysed using random effects models.
382 pregnancies occurred in 302/1,867 (16%) women (4.4/100 woman-years [95% CI 4.0–4.9]). 226/390 (58%) outcomes were live-births, 27 (7%) stillbirths (≥22 wk), and 137 (35%) terminations/miscarriages (<22 wk). Of 226 live-births, seven (3%) infants died <2 wk from perinatal causes and there were seven (3%) congenital abnormalities, with no effect of in utero tenofovir exposure (p>0.4). Of 219 surviving infants, 182 (83%) enrolled in the follow-up study; median (interquartile range [IQR]) age at last visit was 25 (12–38) months. From mothers' ART, 62/9/111 infants had no/20%–89%/≥90% in utero tenofovir exposure; most were also zidovudine/lamivudine exposed. All 172 infants tested were HIV-negative (ten untested). Only 73/182(40%) infants were breast-fed for median 94 (IQR 75–212) days. Overall, 14 infants died at median (IQR) age 9 (3–23) months, giving 5% 12-month mortality; six of 14 were HIV-uninfected; eight untested infants died of respiratory infection (three), sepsis (two), burns (one), measles (one), unknown (one). During follow-up, no bone fractures were reported to have occurred; 12/368 creatinines and seven out of 305 phosphates were grade one (16) or two (three) in 14 children with no effect of in utero tenofovir (p>0.1). There was no evidence that in utero tenofovir affected growth after 2 years (p = 0.38). Attained height- and weight for age were similar to general (HIV-uninfected) Ugandan populations. Study limitations included relatively small size and lack of randomisation to maternal ART regimens.
Conclusions
Overall 1-year 5% infant mortality was similar to the 2%–4% post-neonatal mortality observed in this region. No increase in congenital, renal, or growth abnormalities was observed with in utero tenofovir exposure. Although some infants died untested, absence of recorded HIV infection with combination ART in pregnancy is encouraging. Detailed safety of tenofovir for pre-exposure prophylaxis will need confirmation from longer term follow-up of larger numbers of exposed children.
Trial registration
www.controlled-trials.com ISRCTN13968779
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Currently, about 34 million people (mostly in low- and middle-income countries) are infected with HIV, the virus that causes AIDS. At the beginning of the epidemic, more men than women were infected with HIV but now about half of all people living with HIV/AIDS are women, most of who became infected through unprotected sex with an infected partner. In sub-Saharan Africa alone, 12 million women are HIV-positive. Worldwide, HIV/AIDS is the leading cause of death among women of child-bearing age. Moreover, most of the 400,000 children who become infected with HIV every year acquire the virus from their mother during pregnancy or birth, or through breastfeeding, so-called mother-to-child transmission (MTCT). Combination antiretroviral therapy (ART)—treatment with cocktails of powerful antiretroviral drugs—reduces HIV-related illness and death among women, and ART given to HIV-positive mothers during pregnancy and delivery and to their newborn babies greatly reduces MTCT.
Why Was This Study Done?
Because of ongoing international efforts to increase ART coverage, more HIV-positive women in Africa have access to ART now than ever before. However, little is known about pregnancy outcomes among HIV-infected African women taking ART throughout pregnancy for their own health or about the long-term outcomes of their offspring. In particular, few studies have examined the effect of taking tenofovir (an antiretroviral drug that is now recommended as part of first-line ART) throughout pregnancy. Tenofovir readily crosses from mother to child during pregnancy and, in animal experiments, high doses of tenofovir given during pregnancy caused bone demineralization (which weakens bones), kidney problems, and impaired growth among offspring. In this study, the researchers analyze data collected on pregnancy and infant outcomes among Ugandan and Zimbabwean HIV-positive women who took ART throughout pregnancy in the Development of AntiRetroviral Therapy in Africa (DART) trial. This trial was designed to test whether ART could be safely and effectively delivered in Africa without access to the expensive laboratory tests that are routinely used to monitor ART toxicity and efficacy in developed countries.
What Did the Researchers Do and Find?
The pregnancy outcomes of 302 women who became pregnant during the DART trial and information on birth defects among their babies were collected as part of the DART protocol; information on the survival, growth, and development of the infants born to these women was collected in a separate infant study. Most of the women who became pregnant were taking tenofovir-containing ART before and throughout their pregnancies. 58% of the pregnancies resulted in a live birth, 7% resulted in a stillbirth (birth of a dead baby at any time from 22 weeks gestation to the end of pregnancy), and 35% resulted in a termination or miscarriage (before 22 weeks gestation). Of the 226 live births, seven infants died within 2 weeks and seven had birth defects. Similar proportions of the infants exposed and not exposed to tenofovir during pregnancy died soon after birth or had birth defects. Of the 182 surviving infants who were enrolled in the infant study, 14 subsequently died at an average age of 9 months, giving a 1-year mortality of 5%. None of the surviving children who were tested (172 infants) were HIV infected. No bone fractures or major kidney problems occurred during follow-up and prebirth exposure to tenofovir in utero had no effect on growth or weight gain at 2 years (in contrast to a previous US study).
What Do These Findings Mean?
By showing that prebirth tenofovir exposure does not affect pregnancy outcomes or increase birth defects, growth abnormalities, or kidney problems, these findings support the use of tenofovir-containing ART during pregnancy among HIV-positive African women, and suggest that it could also be used to prevent women of child-bearing age acquiring HIV-infection heterosexually. Notably, the observed 5% 1-year infant mortality is similar to the 2%–4% infant mortality normally seen in the region. The absence of HIV infection among the infants born to the DART participants is also encouraging. However, this is a small study (only 111 infants were exposed to tenofovir throughout pregnancy) and women were not randomly assigned to receive tenofovir-containing ART. Consequently, more studies are needed to confirm that tenofovir exposure during pregnancy does not affect pregnancy outcomes or have any long-term effects on infants. Such studies are essential because the use of tenofovir as a treatment for women who are HIV-positive is likely to increase and tenofovir may also be used in the future to prevent HIV acquisition in HIV-uninfected women.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001217.
Information is available from the US National Institute of Allergy and infectious diseases on all aspects of HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment (in several languages)
Information is available from Avert, an international AIDS nonprofit on many aspects of HIV/AIDS, including detailed information on HIV/AIDS treatment and care, women, HIV and AIDS, children, HIV and AIDS, and on HIV/AIDS and pregnancy (some information in English and Spanish); personal stories of women living with HIV are available
More information about the DART trial is available
Additional patient stories about living with HIV/AIDS are available through the nonprofit website Healthtalkonline
doi:10.1371/journal.pmed.1001217
PMCID: PMC3352861  PMID: 22615543
6.  Poor Adherence to National and International Breastfeeding Duration Targets in an Australian Longitudinal Cohort 
PLoS ONE  2013;8(1):e54409.
Objectives
To report on the proportion and characteristics of Australian infants who are fed, and mothers who feed, in accordance with the national and international breastfeeding duration targets of six, 12 and 24 months. Furthermore, to examine the longitudinal breastfeeding duration patterns for women with more than one child.
Methods
Breastfeeding duration data for 9773 children have been self-reported by a national sample of 5091 mothers aged 30–36 years in 2009, participating in the Australian Longitudinal Study on Women’s Health.
Results
Only 60% of infants received the minimum recommended 6 months of breast milk, irrespective of breastfeeding exclusivity. Less than 30% of infants received any breast milk at 12 months, and less than 3% were breastfed to the international target of 24 months. Young, less educated, unmarried or low-income women were at an increased risk of premature breastfeeding cessation. For women with three or more children, nearly 75% of women who breastfed their first child for at least six months reached this breastfeeding duration target for their next two children.
Conclusion
While national breastfeeding rates are typically evaluated in relation to the infant, a novel component of our study is that we have assessed maternal adherence to breastfeeding duration targets and the longitudinal feeding practices of women with more than one child. Separate evaluations of maternal and infant breastfeeding rates are important as they differ in their implications for public health policy and practice.
doi:10.1371/journal.pone.0054409
PMCID: PMC3559550  PMID: 23382897
7.  Infant feeding in the context of HIV: a qualitative study of health care workers’ knowledge of recommended infant feeding options in Papua New Guinea 
Background
Interventions to prevent mother to child transmission of human immunodeficiency virus (HIV) during childbirth and breastfeeding can reduce HIV infections in infants to less than 5% in low and middle income countries. The World Health Organization (WHO) recommends all mothers, regardless of their HIV status, practice exclusive breastfeeding for the first six months of an infant’s life. In line with these recommendations and to protect, promote and support breastfeeding, in 2009 the PNG National Department of Health revised their National HIV infant feeding guidelines, reinforcing the WHO recommendation of exclusive breastfeeding for the first six months followed by the introduction of other food and fluids, while continuing breastfeeding.
The overall aim of this paper is to explore health care workers’ knowledge regarding infant feeding options in PNG, specifically as they relate to HIV exposed infants.
Methods
As part of a study investigating women’s and men’s experiences of prevention of mother to child transmission (PMTCT) services in two sites in PNG, 28 key informant interviews were undertaken. This paper addresses one theme that emerged from thematic data analysis: Health care workers’ knowledge regarding infant feeding options, specifically how this knowledge reflects the Papua New Guinea National HIV Care and Treatment Guidelines on HIV and infant feeding (2009).
Results
Most informants mentioned exclusive breastfeeding, the majority of whom reflected the most up-to-date National Guidelines of exclusive breastfeeding for six months. The importance of breastfeeding continuing beyond this time, along with the introduction of food and fluids was less well understood. The most senior people involved in PMTCT were the informants who most accurately reflected the national guidelines of continuing breastfeeding after six months.
Conclusion
Providing advice on optimal infant feeding in resource poor settings is problematic, especially in relation to HIV transmission. Findings from our study reflect those found elsewhere in identifying that key health care workers are not aware of up-to-date information relating to infant feeding, especially within the context of HIV. Greater emphasis needs to be placed on ensuring the most recent feeding guidelines are disseminated and implemented in clinical practice in PNG.
doi:10.1186/1746-4358-8-6
PMCID: PMC3681562  PMID: 23742201
Prevention of mother to child transmission; Infant feeding practices; Exclusive breastfeeding; Health care worker knowledge
8.  HIV and infant feeding in Malawi: public health simplicity in complex social and cultural contexts 
BMC Public Health  2012;12:700.
Background
The question of when and how to best wean infants born to mothers with HIV requires complex answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse low-income settings. In such settings, infant-feeding practices are not only dependent on individual women’s choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early age of six months and b) explore how the women adhered to their infant-feeding options while facing and managing these challenges.
Methods
This study was conducted between February 2008 and April 2009 at two public health facilities where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included home visits.
Results
Several interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure on them to ignore the medical advice.
Conclusions
The infant-feeding dilemmas for women with HIV are complex. The integration of public health efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome these challenges.
doi:10.1186/1471-2458-12-700
PMCID: PMC3489588  PMID: 22925437
9.  Complementary feeding adequacy in relation to nutritional status among early weaned breastfed children who are born to HIV-infected mothers: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire 
Pediatrics  2006;117(4):e701-e710.
Background
In high HIV-prevalence resource constrained settings, exclusive breastfeeding with early cessation is one of the conceivable interventions aimed at the prevention of HIV through breastmilk. Nevertheless, this intervention has potential adverse effects such as the inappropriateness of complementary feeding taking over breastmilk.
Design
Prospective cohort study in Abidjan, Côte d’Ivoire.
Methods
HIV-infected pregnant women willing to breastfeed who had received a perinatal antiretroviral prophylaxis were offered to practice exclusive breastfeeding and initiate early cessation of breastfeeding from the fourth month to reduce breastmilk HIV transmission. Nature and ages of introductory complementary feeding were described in infants up to their first birthday by longitudinal compilation of 24 hour and seven day recall histories. These recalls were done weekly until six weeks of age, monthly until nine months of age, and then quarterly. We created an index synthesizing the nutritional adequacy of infant feeding practices (in terms of quality of the source of milk, dietary diversity, food and meal frequencies) ranging from 0 to 12. The association of this feeding index with growth outcomes in children was investigated.
Results
Among the 262 breastfed children included, complete cessation of breastfeeding occurred in 77% by their first birthday, with a median duration of four months. Most of the complementary foods were introduced within the seventh month of life, except for baby food and infant formula that were introduced at age four months. The feeding index was relatively low (5/12) at age six months, mainly due to insufficient dietary diversity, but was improved in the next six months (8.5/12 at age 12 months). Inadequate complementary feeding at age six months was associated with impaired growth during the next 12 months, with a 37% increased probability of stunting.
Conclusion
Adequate feeding practices around the weaning period are thus crucial to achieve optimal child growth. HIV-infected women should only turn to early cessation of breastfeeding when they are properly counselled to provide adequate complementary feeding taking over breastmilk. Our child feeding index could contribute to the assessment of the nutritional adequacy of complementary feeding around the weaning period and thus help detecting children at risk of malnutrition.
doi:10.1542/peds.2005-1911
PMCID: PMC2098879  PMID: 16585284
Breast Feeding; Child Development; Cote d'Ivoire; Developing Countries; Disease Transmission, Vertical; prevention & control; Female; Growth; HIV Infections; prevention & control; transmission; Humans; Infant; Infant Food; Infant Formula; Infant Nutrition Physiology; Infant, Newborn; Nutritional Status; Pregnancy; Pregnancy Complications, Infectious; Time Factors; Weaning; Africa; breast feeding; disease transmission, vertical; HIV infections; infant nutrition; nutritional status
10.  What Predicts Intent to Breastfeed Exclusively? Breastfeeding Knowledge, Attitudes, and Beliefs in a Diverse Urban Population 
Breastfeeding Medicine  2011;6(6):413-420.
Abstract
Background
Maternal knowledge and comfort with breastfeeding affect prenatal feeding intentions, and these intentions are strong predictors of feeding outcomes. However, predictors of exclusive breastfeeding intention have not been well characterized.
Methods
We measured the association between intentions to exclusively breastfeed and knowledge of infant health benefits, feeding guidelines, and comfort related to breastfeeding in social settings. Participants were lower-income, ethnically diverse women in two randomized, controlled trials of breastfeeding support. We compared results with data from the national Infant Feeding Practices Study II.
Results
Among 883 women in our trials, exclusive breastfeeding, mixed feeding, and exclusive formula feeding intentions were 45.9%, 46.1%, and 8.0%, respectively. In multivariate-adjusted models, women who disagreed that “Infant formula is as good as breastmilk” were more likely to intend exclusive breastfeeding versus exclusive formula feeding (odds ratio 3.44, 95% confidence interval 1.80–6.59) compared with women who agreed with this statement. Increasing levels of agreement that breastfed infants were less likely to develop ear infections, respiratory infections, diarrhea, and obesity were positively associated with intentions to exclusively breastfeed (p for trend < 0.001 for all). Compared with the national sample, our study participants were more likely to agree with all of these statements. Women who felt comfortable breastfeeding in public intended to exclusive breastfeed for 0.84 month longer (95% confidence interval 0.41–1.28) than those who felt uncomfortable.
Conclusions
Maternal knowledge about infant health benefits, as well as comfort with breastfeeding in social settings, was directly related to intention to exclusively breastfeed. Prenatal interventions that address these issues may increase exclusive breastfeeding intention and duration.
doi:10.1089/bfm.2010.0088
PMCID: PMC3263301  PMID: 21342016
11.  Triple-Antiretroviral Prophylaxis to Prevent Mother-To-Child HIV Transmission through Breastfeeding—The Kisumu Breastfeeding Study, Kenya: A Clinical Trial 
PLoS Medicine  2011;8(3):e1001015.
Timothy Thomas and colleagues report the results of the Kisumu breastfeeding study (Kenya), a single-arm trial that assessed the feasibility and safety of a triple-antiretroviral regimen to suppress maternal HIV load in late pregnancy.
Background
Effective strategies are needed for the prevention of mother-to-child HIV transmission (PMTCT) in resource-limited settings. The Kisumu Breastfeeding Study was a single-arm open label trial conducted between July 2003 and February 2009. The overall aim was to investigate whether a maternal triple-antiretroviral regimen that was designed to maximally suppress viral load in late pregnancy and the first 6 mo of lactation was a safe, well-tolerated, and effective PMTCT intervention.
Methods and Findings
HIV-infected pregnant women took zidovudine, lamivudine, and either nevirapine or nelfinavir from 34–36 weeks' gestation to 6 mo post partum. Infants received single-dose nevirapine at birth. Women were advised to breastfeed exclusively and wean rapidly just before 6 mo. Using Kaplan-Meier methods we estimated HIV-transmission and death rates from delivery to 24 mo. We compared HIV-transmission rates among subgroups defined by maternal risk factors, including baseline CD4 cell count and viral load.
Among 487 live-born, singleton, or first-born infants, cumulative HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were 2.5%, 4.2%, 5.0%, 5.7%, and 7.0%, respectively. The 24-mo HIV-transmission rates stratified by baseline maternal CD4 cell count <500 and ≥500 cells/mm3 were 8.4% (95% confidence interval [CI] 5.8%–12.0%) and 4.1% (1.8%–8.8%), respectively (p = 0.06); the corresponding rates stratified by baseline maternal viral load <10,000 and ≥10,000 copies/ml were 3.0% (1.1%–7.8%) and 8.7% (6.1%–12.3%), respectively (p = 0.01). None of the 12 maternal and 51 infant deaths (including two second-born infants) were attributed to antiretrovirals. The cumulative HIV-transmission or death rate at 24 mo was 15.7% (95% CI 12.7%–19.4%).
Conclusions
This trial shows that a maternal triple-antiretroviral regimen from late pregnancy through 6 months of breastfeeding for PMTCT is safe and feasible in a resource-limited setting. These findings are consistent with those from other trials using maternal triple-antiretroviral regimens during breastfeeding in comparable settings.
Trial registration
ClinicalTrials.gov NCT00146380
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about half a million children become infected with human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS). Nearly all these newly infected children live in resource-limited countries and most acquire HIV from their mother, so-called mother-to-child transmission (MTCT). Without intervention, 25%–50% of babies born to HIV-positive mothers become infected with HIV during pregnancy, delivery, or breastfeeding. This infection rate can be reduced by treating mother and child with antiretroviral (ARV) drugs. A single dose of nevirapine (a “non-nucleoside reverse transcriptase inhibitor” or NNRTI) given to the mother at the start of labor and to her baby soon after birth nearly halves the risk of MTCT. Further reductions in risk can be achieved by giving mother and baby three ARVs—an NNRTI and two nucleoside reverse transcriptase inhibitors (NRTIs such as zidovudine and lamivudine)—during pregnancy and perinatally (around the time of birth).
Why Was This Study Done?
Breastfeeding is crucial for child survival in poor countries but it is also responsible for up to half of MTCT. Consequently, many researchers are investigating how various ARV regimens given to mothers and/or their infants during the first few months of life as well as during pregnancy and perinatally affect MTCT. In this single-arm trial, the researchers assess the feasibility and safety of using a triple-ARV regimen to suppress the maternal HIV load (amount of virus in the blood) from late pregnancy though 6 months of breastfeeding among HIV-positive women in Kisumu, Kenya, and ask whether this approach achieves a lower HIV transmission rate than other ARV regimens that have been tested in resource-limited settings. In a single-arm trial, all the participants are given the same treatment. By contrast, in a “randomized controlled” trial, half the participants chosen at random are given the treatment under investigation and the rest are given a control treatment. A randomized controlled trial provides a better comparison of treatments than a single-arm trial but is more costly.
What Did the Researchers Do and Find?
In the Kisumu Breastfeeding Study (KiBS), HIV-infected pregnant women took a triple-ARV regimen containing zidovudine and lamivudine and either nevirapine or the protease inhibitor nelfinavir from 34–36 weeks of pregnancy to 6 months after delivery. They were advised to breastfeed their babies (who received single-dose nevirapine at birth), and to wean them rapidly just before 6 months. The researchers then used Kaplan-Meier statistical methods to estimate HIV transmission and death rates among 487 live-born infants from delivery to 24 months. The cumulative HIV transmission rate rose from 2.5% at birth to 7.0% at 24 months. The cumulative HIV transmission or death rate at 24 months was 15.7%; no infant deaths were attributed to ARVs. At 24 months, 3.0% of babies born to mothers with a low viral load were HIV positive compared to 8.7% of babies born to mothers with a high viral load, a statistically significant difference. Similarly, at 24 months, 8.4% of babies born to mothers with low baseline CD4 cell counts (CD4 cells are immune system cells that are killed by HIV; CD4 cell counts indicate the level of HIV-inflicted immune system damage) were HIV positive compared to 4.1% of babies born to mothers with high baseline CD4 cell counts, although this difference did not achieve statistical significance.
What Do These Findings Mean?
Although these findings are limited by the single-arm design, they support the idea that giving breastfeeding women a triple-ARV regimen from late pregnancy to 6 months is a safe, feasible way to reduce MTCT in resource-limited settings. The HIV transmission rates in this study are comparable to those recorded in similar trials in other resource-limited settings and are lower than MTCT rates observed previously in Kisumu in a study in which no ARVs were used. Importantly, the KiBS mothers took most of the ARVs they were prescribed and most stopped breastfeeding by 6 months as advised. The intense follow-up employed in KiBS may be partly responsible for this good adherence to the trial protocol and thus this study's findings may not be generalizable to all resource-limited settings. Nevertheless, they suggest that a simple triple-ARV regimen given to HIV-positive pregnant women regardless of their baseline CD4 cell count can reduce MTCT during pregnancy and breastfeeding in resource-limited setting.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001015.
The accompanying PLoS Medicine Research article by Zeh and colleagues describes the emergence of resistance to ARVs in KiBS
Information on HIV and AIDS is available from the US National Institute of Allergy and Infectious Diseases
HIV InSite has comprehensive information on all aspects of HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on children, HIV, and AIDS and on preventing mother-to-child transmission of HIV (in English and Spanish)
UNICEF also has information about children and HIV and AIDS (in several languages)
The World Health organization has information on mother-to-child transmission of HIV http://www.who.int/hiv/topics/mtct/en/index.html (in several languages)
doi:10.1371/journal.pmed.1001015
PMCID: PMC3066129  PMID: 21468300
12.  HIV: prevention of mother-to-child transmission  
Clinical Evidence  2011;2011:0909.
Introduction
Over 2 million children are thought to be living with HIV/AIDS worldwide, of whom over 80% live in sub-Saharan Africa. Without antiretroviral treatment, the risk of HIV transmission from infected mothers to their children is 15% to 30% during gestation or labour, with an additional transmission risk of 10% to 20% associated with prolonged breastfeeding. HIV-1 infection accounts for most infections; HIV-2 is rarely transmitted from mother to child. Transmission is more likely in mothers with high viral loads, advanced disease, or both, in the presence of other sexually transmitted diseases, and with increased exposure to maternal blood. Mixed feeding practices (breast milk plus other liquids or solids) and prolonged breastfeeding are also associated with increased risk of mother-to-child transmission of HIV.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of measures to reduce mother-to-child transmission of HIV? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed a GRADE evaluation of the quality of evidence for interventions.
Results
We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiretroviral drugs, different methods of infant feeding, elective caesarean section, immunotherapy, micronutrient supplements, vaginal microbicides, and vitamin supplements.
Key Points
Without active intervention, the risk of mother-to-child transmission (MTCT) of HIV-1 is high, especially in populations where prolonged breastfeeding is the norm. Without antiviral treatment, the risk of transmission of HIV from infected mothers to their children is approximately 15% to 30% during pregnancy and labour, with an additional transmission risk of 10% to 20% associated with prolonged breastfeeding.HIV-2 is rarely transmitted from mother to child.Transmission is more likely in mothers with high viral loads, advanced HIV disease, or both.Without antiretroviral treatment (ART), 15% to 35% of vertically infected infants die within the first year of life.The long-term treatment of children with ART is complicated by multiple concerns regarding the complications associated with life-long treatment, including adverse effects of antiretroviral drugs, difficulties of adherence across the developmental trajectory of childhood and adolescence, and the development of resistance.From a paediatric perspective, successful prevention of MTCT and HIV-free survival for infants remain the most important focus.
Antiretroviral drugs given to the mother during pregnancy or labour, to the baby immediately after birth, or to the mother and baby reduce the risk of intrauterine and intrapartum MTCT of HIV-1 and when given to the infant after birth and to the mother or infant during breastfeeding reduce the risk of postpartum MTCT of HIV-1.
Reductions in MTCT are possible using multidrug ART regimens. Longer courses of ART are more effective, but the greatest benefit is derived from treatment during late pregnancy, labour, and early infancy.Suppression of the maternal viral load to undetectable levels (below 50 copies/mL) using highly active antiretroviral therapy (HAART) offers the greatest risk reduction, and is currently the standard of care offered in most resource-rich countries, where MTCT rates have been reduced to 1% to 2%. Alternative short-course regimens have been tested in resource-limited settings where HAART is not yet widely available. There is evidence that short courses of antiretroviral drugs have confirmed efficacy for reducing MTCT. Identifying optimal short-course regimens (drug combination, timing, and cost effectiveness) for various settings remains a focus for ongoing research.The development of viral resistance in mothers and infants after single-dose nevirapine and other short-course regimens that include single-dose nevirapine is of concern. An additional short-course of antiretrovirals with a different regimen during labour and early postpartum, and the use of HAART, may decrease the risk of viral resistance in mothers, and in infants who become HIV-infected despite prophylaxis.World Health Organization guidelines recommend starting prophylaxis with antiretroviral drugs from as early as 14 weeks' gestation, or as soon as possible if women present late in pregnancy, in labour, or at delivery.
Elective caesarean section at 38 weeks may reduce vertical transmission rates (apart from breast-milk transmission). The potential benefits of this intervention need to be balanced against the increased risk of surgery-associated complications, high cost, and feasibility issues. These reservations are particularly relevant in resource-limited settings.
Immunotherapy with HIV hyperimmune globulin seems no more effective than immunoglobulin without HIV antibody at reducing HIV-1 MTCT risk.
Vaginal microbicides have not been demonstrated to reduce HIV-1 MTCT risk.
There is no evidence that supplementation with vitamin A reduces the risk of HIV-1 MTCT, and there is concern that postnatal vitamin A supplementation for mother and infant may be associated with increased risk of mortality.
We don't know whether micronutrients are effective in prevention of MTCT of HIV as we found no RCT evidence on this outcome.
Avoidance of breastfeeding prevents postpartum transmission of HIV, but formula feeding requires access to clean water and health education. The risk of breastfeeding-related HIV transmission needs to be balanced against the multiple benefits that breastfeeding offers. In resource-poor countries, breastfeeding is strongly associated with reduced infant morbidity and improved child survival. Exclusive breastfeeding during the first 6 months may reduce the risk of HIV transmission compared with mixed feeding, while retaining most of its associated benefits.In a population where prolonged breastfeeding is usual, early, abrupt weaning may not reduce MTCT or HIV-free survival at 2 years compared with prolonged breastfeeding, and may be associated with a higher rate of infant mortality for those infants diagnosed as HIV-infected at <4 months of age. Antiretrovirals given to the mother or the infant during breastfeeding can reduce the risk of HIV transmission in the postpartum period. World Health Organization guidelines recommend that HIV-positive mothers should exclusively breastfeed for the first 6 months, after which time appropriate complementary foods can be introduced. Breastfeeding should be continued for the first 12 months of the infant's life, and stopped only when an adequate diet without breast milk can be provided. Heat- or microbicidal-treated expressed breast milk may offer value in particular settings.
PMCID: PMC3217724  PMID: 21477392
13.  Determinants of breastfeeding initiation among mothers in Kuwait 
Background
Exclusive breastfeeding is recommended as the optimal way to feed infants for the first six months of life. While overall breastfeeding rates are high, exclusive breastfeeding is relatively uncommon among Middle Eastern women. The objective of this study was to identify the incidence of breastfeeding amongst women in the six governorates of Kuwait and the factors associated with the initiation of breastfeeding.
Methods
A sample of 373 women (aged 17-47 years), recruited shortly after delivery from four hospitals in Kuwait, completed a structured, interviewer-administered questionnaire. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.
Results
In total, 92.5% of mothers initiated breastfeeding and at discharge from hospital the majority of mothers were partially breastfeeding (55%), with only 30% of mothers fully breastfeeding. Prelacteal feeding was the norm (81.8%) and less than 1 in 5 infants (18.2%) received colostrum as their first feed. Only 10.5% of infants had been exclusively breastfed since birth, the remainder of the breastfed infants having received either prelacteal or supplementary infant formula feeds at some time during their hospital stay. Of the mothers who attempted to breastfeed, the majority of women (55.4%) delayed their first attempt to breastfeed until 24 hours or more after delivery. Breastfeeding at discharge from hospital was positively associated with paternal support for breastfeeding and negatively associated with delivery by caesarean section and with the infant having spent time in the Special Care Nursery.
Conclusions
The reasons for the high use of prelacteal and supplementary formula feeding warrant investigation. Hospital policies and staff training are needed to promote the early initiation of breastfeeding and to discourage the unnecessary use of infant formula in hospital, in order to support the establishment of exclusive breastfeeding by mothers in Kuwait.
doi:10.1186/1746-4358-5-7
PMCID: PMC2917400  PMID: 20667112
14.  Breastfeeding and Smoking among Low-Income Women: Results of a Longitudinal Qualitative Study 
Birth (Berkeley, Calif.)  2008;35(3):230-240.
Background
The benefits of breastfeeding for infants and mothers have been well established, yet rates of breastfeeding remain well below national recommendations in the United States and even lower for women who smoke during pregnancy. Primary goals of this study were to explore contextual factors that contribute to breastfeeding intentions and behavior and to examine how smoking status affected women’s decision making about breastfeeding.
Methods
This paper is based on a longitudinal qualitative study of smoking, pregnancy, and breastfeeding among 44 low-income women in the southwest U.S. who smoked during pregnancy. Each woman was interviewed 9 times; 6 times during pregnancy and 3 times postpartum using semistructured questionnaires. Interviews lasted 1 to 3 hours and were tape-recorded, transcribed, and analyzed.
Results
Despite 36 (82%) respondents stating that they intended to breastfeed for an average duration of 8 months, rates of breastfeeding initiation and duration were much lower than intentions. By 6 months postpartum, only two women were breastfeeding exclusively.
Conclusions
Women perceived that a strong risk of harming the baby was posed by smoking while breastfeeding and received little encouragement to continue breastfeeding despite an inability to stop smoking. The perceptions of the toxic, addictive, and harmful effects of smoking on breastmilk constitution and quantity factored into reasons why women weaned their infants from breastfeeding much earlier than the recommended 6 months. The results indicate a need for more consistency and routine in educating women on the relationship between smoking and breastfeeding and in promoting breastfeeding in spite of smoking postpartum. (BIRTH 35:3 September 2008)
doi:10.1111/j.1523-536X.2008.00244.x
PMCID: PMC2830716  PMID: 18844649
smoking; breastfeeding; weaning; qualitative data; harm perceptions
15.  A cohort study of infant feeding practices in city, suburban and rural areas in Zhejiang Province, PR China 
Background
Breastfeeding is the basis for appropriate nutrition for infants and is strongly supported by the Ministry of Health in China. However, there are differences in infant feeding practices in different areas of the country. The aim of this study was to compare the infant feeding practices and the prevalence of determinants of initiation and continuing to breastfeed until six months of age in city, suburb and rural areas in Zhejiang Province, PRC.
Methods
A longitudinal cohort study of infant feeding practices was undertaken in city, suburban and rural areas in 2004/2005. Mothers were recruited and interviewed before discharge from hospitals. A total of 1520 mothers were recruited into the study. Follow-up interviews were administered at 1, 3 and 6 months after birth to obtain details of infant feeding practices.
Results
'Any breastfeeding' rates were high before discharge at all three locations, 96.5% in city, 96.8% in suburb and 97.4% in the rural area. The 'exclusive breastfeeding' rates in the city, suburban and rural areas before discharge were 38.0%, 63.4% and 61.0% respectively. By sixth months the 'any breastfeeding' rates had declined to 62.8%, 76.9% and 83.6% and the 'exclusive breastfeeding' rates had fallen to 0.2%, 0.5% and 7.2% in city, suburb and rural areas respectively. There were differences in feeding practices between the three locations, including the use of prelacteal feeds and the introduction of supplementary feeds.
Conclusion
Mothers who lived in the city were least likely to be 'exclusive breastfeeding' at discharge. At six months the city infants also had lower rates of 'any breastfeeding' and 'exclusive breastfeeding'.
doi:10.1186/1746-4358-3-4
PMCID: PMC2292702  PMID: 18315865
16.  Breastfeeding practices in a public health field practice area in Sri Lanka: a survival analysis 
Background
Exclusive breastfeeding up to the completion of the sixth month of age is the national infant feeding recommendation for Sri Lanka. The objective of the present study was to collect data on exclusive breastfeeding up to six months and to describe the association between exclusive breastfeeding and selected socio-demographic factors.
Methods
A clinic based cross-sectional study was conducted in the Medical Officer of Health area, Beruwala, Sri Lanka in June 2006. Mothers with infants aged 4 to 12 months, attending the 19 child welfare clinics in the area were included in the study. Infants with specific feeding problems (cleft lip and palate and primary lactose intolerance) were excluded. Cluster sampling technique was used and consecutive infants fulfilling the inclusion criteria were enrolled. A total of 219 mothers participated in the study. The statistical tests used were survival analysis (Kaplan-Meier survival curves and Cox proportional Hazard model).
Results
All 219 mothers had initiated breastfeeding. The median duration of exclusive breastfeeding was four months (95% CI 3.75, 4.25). The rates of exclusive breastfeeding at 4 and 6 months were 61.6% (135/219) and 15.5% (24/155) respectively. Bivariate analysis showed that the Muslim ethnicity (p = 0.004), lower levels of parental education (p < 0.001) and being an unemployed mother (p = 0.021) were important associations of early cessation of exclusive breastfeeding. At the time of the study, 62% (135/219) of infants were receiving feeds via a bottle and 23% (51/219) were receiving infant formula. Muslim ethnicity was significantly associated with bottle and formula feeding (p < 0.001). Bottle feeding was also significantly higher among mothers with a low level of education and among employed mothers.
Conclusion
The rate of breastfeeding initiation and exclusive breastfeeding up to the fourth month is very high in Medical Officer of Health area, Beruwala, Sri Lanka. However exclusive breastfeeding up to six months is still low and the prevalence of inappropriate feeding practices is high.
doi:10.1186/1746-4358-2-13
PMCID: PMC2092417  PMID: 17927840
17.  HIV-1 Drug Resistance Emergence among Breastfeeding Infants Born to HIV-Infected Mothers during a Single-Arm Trial of Triple-Antiretroviral Prophylaxis for Prevention of Mother-To-Child Transmission: A Secondary Analysis 
PLoS Medicine  2011;8(3):e1000430.
Analysis of a substudy of the Kisumu breastfeeding trial by Clement Zeh and colleagues reveals the emergence of HIV drug resistance in HIV-positive infants born to HIV-infected mothers treated with antiretroviral drugs.
Background
Nevirapine and lamivudine given to mothers are transmitted to infants via breastfeeding in quantities sufficient to have biologic effects on the virus; this may lead to an increased risk of a breastfed infant's development of resistance to maternal antiretrovirals. The Kisumu Breastfeeding Study (KiBS), a single-arm open-label prevention of mother-to-child HIV transmission (PMTCT) trial, assessed the safety and efficacy of zidovudine, lamivudine, and either nevirapine or nelfinavir given to HIV-infected women from 34 wk gestation through 6 mo of breastfeeding. Here, we present findings from a KiBS trial secondary analysis that evaluated the emergence of maternal ARV-associated resistance among 32 HIV-infected breastfed infants.
Methods and Findings
All infants in the cohort were tested for HIV infection using DNA PCR at multiple study visits during the 24 mo of the study, and plasma RNA viral load for all HIV-PCR–positive infants was evaluated retrospectively. Specimens from mothers and infants with viral load >1,000 copies/ml were tested for HIV drug resistance mutations. Overall, 32 infants were HIV infected by 24 mo of age, and of this group, 24 (75%) infants were HIV infected by 6 mo of age. Of the 24 infants infected by 6 mo, nine were born to mothers on a nelfinavir-based regimen, whereas the remaining 15 were born to mothers on a nevirapine-based regimen. All infants were also given single-dose nevirapine within 48 hours of birth. We detected genotypic resistance mutations in none of eight infants who were HIV-PCR positive by 2 wk of age (specimens from six infants were not amplifiable), for 30% (6/20) at 6 wk, 63% (14/22) positive at 14 wk, and 67% (16/24) at 6 mo post partum. Among the 16 infants with resistance mutations by 6 mo post partum, the common mutations were M184V and K103N, conferring resistance to lamivudine and nevirapine, respectively. Genotypic resistance was detected among 9/9 (100%) and 7/15 (47%) infected infants whose mothers were on nelfinavir and nevirapine, respectively. No mutations were detected among the eight infants infected after the breastfeeding period (age 6 mo).
Conclusions
Emergence of HIV drug resistance mutations in HIV-infected infants occurred between 2 wk and 6 mo post partum, most likely because of exposure to maternal ARV drugs through breast milk. Our findings may impact the choice of regimen for ARV treatment of HIV-infected breastfeeding mothers and their infected infants.
Trial Registration
ClinicalTrials.gov NCT00146380
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, more than 2 million children are infected with the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS), and half a million children are newly infected every year. These infections are mainly the result of mother-to-child transmission (MTCT) of HIV during pregnancy, labor and delivery, or through breastfeeding. MTCT can be greatly reduced by treating HIV-positive mothers and their babies with antiretroviral drugs (ARVs). Without ARVs, up to half of babies born to HIV-positive mothers become infected with HIV. This rate of transmission falls to below 5% if a combination of three ARVs is given to the mother throughout pregnancy. Unfortunately, this triple-ARV therapy is too expensive for use in the resource-limited countries where most MTCT occurs. Instead, many such countries have introduced simpler, shorter ARV regimens such as a daily dose of zidovudine (a nucleoside reverse transcriptase inhibitor or NRTI) given to HIV-positive women during late pregnancy coupled with single-dose nevirapine (a non-nucleoside reverse transcriptase inhibitor or NNRTI) at the onset of labor, zidovudine and lamivudine (another NRTI) during labor and delivery, and single-dose nevirapine given to the baby at birth.
Why Was This Study Done?
More than 95% of HIV-exposed children are born in resource-limited settings where breastfeeding is the norm and is crucial for child survival even though it poses a risk of HIV transmission. Consequently, several recent studies have investigated whether MTCT can be further reduced by giving the mother ARVs while she is breastfeeding. In the Kisumu Breastfeeding Study (KiBS), for example, researchers assessed the effects of giving zidovudine, lamivudine, and either nevirapine or nelfinavir (a protease inhibitor) to HIV-infected women from 34 weeks of pregnancy through 6 months of breastfeeding. The results of KiBS indicate that this approach might be a safe, feasible way to reduce MTCT (see the accompanying paper by Thomas and colleagues). However, low amounts of nevirapine and lamivudine are transferred from mother to infant in breast milk and this exposure to ARVs could induce the development of resistance to ARVs among HIV-infected infants. In this KiBS substudy, the researchers investigate whether HIV drug resistance emerged in any of the HIV-positive infants in the parent study.
What Did the Researchers Do and Find?
In KiBS, 32 infants were HIV-positive at 24 months old; 24 were HIV-positive at 6 months old when their mothers stopped taking ARVs and when breastfeeding was supposed to stop. The researchers analyzed blood samples taken from these infants at various ages and from their mothers for the presence of HIV drug resistance mutations (DNA changes that make HIV resistant to killing by ARVs). They detected no resistance mutations in samples taken from 2-week old HIV-positive infants or from the infants who became infected after the age of 6 months. However, they found resistance mutations in a third and two-thirds of samples taken from 6-week and 6-month old HIV-positive infants, respectively. The commonest mutations conferred resistance to lamivudine and nevirapine. Moreover, resistance mutations were present in samples taken from all the HIV-positive infants whose mothers who had received nelfinavir but in only half those taken from infants whose mothers who had received nevirapine. Finally, most of the mothers of HIV-positive infants had no HIV drug resistance mutations, and only one mother-infant pair had an overlapping pattern of HIV drug resistance mutations.
What Do These Findings Mean?
These findings indicate that, in this KiBS substudy, the emergence of HIV drug resistance mutations in HIV-infected infants whose mothers were receiving ARVs occurred between 2 weeks and 6 months after birth. The pattern of mutations suggests that drug resistance most likely arose through exposure of the infants to low levels of ARVs in breast milk rather than through MTCT of drug-resistant virus. These findings need confirming but suggest that infants exposed to ARVs through breast milk—a situation that may become increasingly common given the reduction in MTCT seen in KiBS and other similar trials—should be carefully monitored for HIV infection. Providers should consider the mothers' regimen when choosing treatment for infants who are found to be HIV-infected despite maternal triple drug prophylaxis. Infants exposed to a maternal regimen with NNRTI drugs should receive first-line therapy with lopinavir/ritonavir, a protease inhibitor. The significance of the NRTI mutations such as M184V with regard to response to therapy needs further evaluation. The M184V mutation may result in hypersensitization to other NRTI drugs and delay or reverse zidovudine resistance. Given the limited availability of alternative drugs for infants in resource-limited settings, provision of the standard WHO-recommended first-line NRTI backbone, which includes 3TC, with enhanced monitoring of the infant to ensure virologic suppression, could be considered. Such an approach should reduce both illness and morbidity among infants who become HIV positive through breastfeeding.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/ 10.1371/journal.pmed.1000430.
The accompanying PLoS Medicine Research article by Thomas and colleagues describes the primary findings of the Kisumu Breastfeeding Study
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on children, HIV, and AIDS and on preventing mother-to-child transmission of HIV (in English and Spanish)
UNICEF also has information about children and HIV and AIDS (in several languages)
The World Health organization has information on mother-to-child transmission of HIV (in several languages), and guidance on the use of ARVs for preventing MTCT
doi:10.1371/journal.pmed.1000430
PMCID: PMC3066134  PMID: 21468304
18.  Factors associated with breastfeeding at six months postpartum in a group of Australian women 
Background
Despite high levels of breastfeeding initiation in Australia, only 47 percent of women are breastfeeding (exclusively or partially) six months later, with marked differences between social groups. It is important to identify women who are at increased risk of early cessation of breastfeeding.
Methods
Data from the three arms of a randomised controlled trial were pooled and analysed as a cohort using logistic regression to identify which factors predicted women continuing to feed any breast milk at six months postpartum. The original trial included 981 primiparous women attending a public, tertiary, women's hospital in Melbourne, Australia in 1999–2001. The trial evaluated the effect of two mid-pregnancy educational interventions on breastfeeding initiation and duration. In the 889 women with six month outcomes available, neither intervention increased breastfeeding initiation nor duration compared to standard care. Independent variables were included in the predictive model based on the literature and discussion with peers and were each tested individually against the dependent variable (any breastfeeding at six months).
Results
Thirty-three independent variables of interest were identified, of which 25 qualified for inclusion in the preliminary regression model; 764 observations had complete data available. Factors remaining in the final model that were positively associated with breastfeeding any breast milk at six months were: a very strong desire to breastfeed; having been breastfed oneself as a baby; being born in an Asian country; and older maternal age. There was an increasing association with increasing age. Factors negatively associated with feeding any breast milk at six months were: a woman having no intention to breastfeed six months or more; smoking 20 or more cigarettes per day pre-pregnancy; not attending childbirth education; maternal obesity; having self-reported depression in the six months after birth; and the baby receiving infant formula while in hospital.
Conclusion
In addition to the factors commonly reported as being associated with breastfeeding in previous work, this study found a negative association between breastfeeding outcomes and giving babies infant formula in hospital, a high maternal body mass index, and self-reported maternal depression or anxiety in the six months after the baby was born. Interventions that seek to increase breastfeeding should consider focusing on women who wish to breastfeed but are at high risk of early discontinuation.
doi:10.1186/1746-4358-1-18
PMCID: PMC1635041  PMID: 17034645
19.  A systematic review of maternal obesity and breastfeeding intention, initiation and duration 
Background
Breastfeeding behaviour is multifactorial, and a wide range of socio-cultural and physiological variables impact on a woman's decision and ability to breastfeed successfully. An association has been reported between maternal obesity and low breastfeeding rates. This is of public health concern because obesity is rising in women of reproductive age and the apparent association with increased artificial feeding will lead to a greater risk of obesity in children. The aim of this paper is to examine the relationship between maternal overweight and obesity and breastfeeding intention and initiation and duration.
Methods
A systematic review was conducted in January and February 2007, using the following databases: Medline, CINAHL and the Australian Breastfeeding Association's Lactation Resource Centre. Studies which have examined maternal obesity and infant feeding intention, initiation, duration and delayed onset of lactation were tabulated and summarised.
Results
Studies have found that obese women plan to breastfeed for a shorter period than normal weight women and are less likely to initiate breastfeeding. Of the four studies that examined onset of lactation, three reported a significant relationship between obesity and delayed lactogenesis. Fifteen studies, conducted in the USA, Australia, Denmark, Kuwait and Russia, have examined maternal obesity and duration of breastfeeding. The majority of large studies found that obese women breastfed for a shorter duration than normal weight women, even after adjusting for possible confounding factors.
Conclusion
There is evidence from epidemiological studies that overweight and obese women are less likely to breastfeed than normal weight women. The reasons may be biological or they may be psychological, behavioral and/or cultural. We urgently need qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.
doi:10.1186/1471-2393-7-9
PMCID: PMC1937008  PMID: 17608952
20.  Early breastfeeding experiences of adolescent mothers: a qualitative prospective study 
Background
Teen mothers face many challenges to successful breastfeeding and are less likely to breastfeed than any other population group in the U.S. Few studies have investigated this population; all prior studies are cross-sectional and collect breastfeeding data retrospectively. The purpose of our qualitative prospective study was to understand the factors that contribute to the breastfeeding decisions and practices of teen mothers.
Methods
This prospective study took place from January through December 2009 in Greensboro, North Carolina in the U.S. We followed the cohort from pregnancy until two weeks after they ceased all breastfeeding and milk expression. We conducted semi-structured interviews at baseline and follow-up, and tracked infant feeding weekly by phone. We analyzed the data to create individual life and breastfeeding journeys and then identified themes that cut across the individual journeys.
Results
Four of the five teenagers breastfed at the breast for nine days: in contrast, one teen breastfed exclusively for five months. Milk expression by pumping was associated with significantly longer provision of human milk. Breastfeeding practices and cessation were closely connected with their experiences as new mothers in the context of ongoing multiple roles, complex living situations, youth and dependency, and poor knowledge of the fundamentals of breastfeeding and infant development. Breastfeeding cessation was influenced by inadequate breastfeeding skill, physically unpleasant and painful early experiences they were unprepared to manage, and inadequate health care response to real problems.
Conclusions
Continued breastfeeding depends on a complex interplay of multiple factors, including having made an informed choice and having the skills, support and experiences needed to sustain the belief that breastfeeding is the best choice for them and their baby given their life situation. Teenagers in the US context need to have a positive early breastfeeding experience, be able to identify and claim a reliable support system supportive of breastfeeding, and gain through their experience, a belief in their own agency and competency as mothers.
doi:10.1186/1746-4358-7-13
PMCID: PMC3565878  PMID: 23020833
Breastfeeding; Adolescent health; Breastfeeding education; Preconception
21.  Racial/Ethnic Differences in Breastfeeding Initiation and Duration Among Low-income, Inner-city Mothers 
Social science quarterly  2009;90(5):1251-1271.
Objectives
Despite the promotion of breastfeeding as the “ideal” infant feeding method by health experts, breastfeeding continues to be less common among low-income and minority mothers than among other women. This paper investigates how maternal socio-demographic and infant characteristics, household environment, and health behaviors are related to breastfeeding initiation and duration among low-income, inner-city mothers, with a specific focus on differences in breastfeeding behavior by race/ethnicity and nativity status.
Methods
Using data from a community-based, longitudinal study of women in Philadelphia, PA (N=1,140), we estimate logistic regression and Cox proportional hazard models to predict breastfeeding initiation and duration.
Results
Both foreign-born black mothers and Hispanic mothers (most of whom were foreign-born) were significantly more likely to breastfeed their infants than non-Hispanic white women, findings that were partly explained by foreign-born and Hispanic mothers’ prenatal intention to breastfeed. In contrast to previous studies, we also found that native-born black women were more likely to breastfeed than non-Hispanic white women.
Conclusion
Our findings suggest that when poor whites and African Americans are similarly situated in an inner-city context, the disparity in their behavior with respect to infant feeding is not as distinct as documented in national surveys. Breastfeeding was also more common among low-income immigrant black women than white or native-born black mothers.
doi:10.1111/j.1540-6237.2009.00656.x
PMCID: PMC2768401  PMID: 20160902
Breastfeeding; Inner-city; Nativity; Race/Ethnicity; SES
22.  Evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes 
We examined how prenatal exposure to breastfeeding information from various media sources, maternal knowledge of benefits, family and clinician support, and peer practices influence breastfeeding outcomes in early infancy. Initiation of breastfeeding, any breastfeeding at two months, and exclusivity of breastfeeding at two months were examined in a cohort of US women using data from the Infant Feeding Practices Study II. Descriptive statistics, chi-square analyses and logistic regression were conducted. Approximately 85 percent of the women initiated breastfeeding. At two months, 63.8 percent continued breastfeeding, while only 38.1 percent breastfed exclusively. Mothers with greater knowledge about breastfeeding benefits were 11.20 (95%CI: 6.87–18.45) times more likely to initiate breastfeeding and 5.62 (95% CI: 4.19–7.54) times more likely to breastfeed at two months than those with lower levels of knowledge. Women whose families prenatally supported exclusive breastfeeding were 8.21(5.12–13.2) times more likely to initiate and continue breastfeeding (OR 3.21, 95%CI: 2.51–4.11). Clinicians who supported breastfeeding only also increased the odds of a woman initiating breastfeeding (OR 1.95, 95% CI: 1.31–2.88). Interventions to increase maternal knowledge of breastfeeding benefits and family and clinician support of breastfeeding in the prenatal period may help increase breastfeeding rates. The encouragement of breastfeeding needs to be a priority among health care providers to improve the health of mothers and infants.
doi:10.1177/1367493512461460
PMCID: PMC4086458  PMID: 23439591
breastfeeding; clinician; exclusive breastfeeding; family; lactation initiation; prenatal
23.  Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study 
Background
Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo.
Methods
Survey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital.
Results
All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included “heat” and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding.
Conclusion
Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.
doi:10.1186/1746-4358-8-11
PMCID: PMC3850507  PMID: 24083882
Breastfeeding; Exclusive breastfeeding; Infant feeding practices; Kinshasa; DR Congo
24.  Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health 
BMC Pediatrics  2012;12:105.
Background
Breastfeeding is a critical component of interventions to reduce child mortality. Exclusive breastfeeding practice is extremely low in South Africa and there has been no improvement in this over the past ten years largely due to fears of HIV transmission. Early cessation of breastfeeding has been found to have negative effects on child morbidity and survival in several studies in Africa. This paper reports on determinants of early breastfeeding cessation among women in South Africa.
Methods
This is a sub group analysis of a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008 (ClinicalTrials.gov no: NCT00397150). Infant feeding recall of 22 food and fluid items was collected at 3, 6, 12 and 24 weeks postpartum. Women’s experiences of breast health problems were also collected at the same time points. 999 women who ever breastfed were included in the analysis. Univariable and multivariable logistic regression analysis adjusting for site, arm and cluster, was performed to determine predictors of stopping breastfeeding by 12 weeks postpartum.
Results
By 12 weeks postpartum, 20% of HIV-negative women and 40% of HIV-positive women had stopped all breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first 3 days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks (Adjusted odds ratio, AOR 5.6, 95% CI 3.4 – 9.5 and AOR 4.1, 95% CI 1.6 – 10.8, respectively). Also important was self-reported breast health problems associated with a 3-fold risk of stopping breastfeeding (AOR 3.1, 95%CI 1.7 – 5.7) and the mother having her own income doubled the risk of stopping breastfeeding (AOR 1.9, 95% CI 1.3 – 2.8).
Conclusion
Early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems.
doi:10.1186/1471-2431-12-105
PMCID: PMC3441849  PMID: 22827969
25.  Breastfeeding Education and Support Trial for Overweight and Obese Women: A Randomized Trial 
Pediatrics  2013;131(1):e162-e170.
OBJECTIVE:
To evaluate a specialized breastfeeding peer counseling (SBFPC) intervention promoting exclusive breastfeeding (EBF) among overweight/obese, low-income women.
METHODS:
We recruited 206 pregnant, overweight/obese, low-income women and randomly assigned them to receive SBFPC or standard care (controls) at a Baby-Friendly hospital. SBFPC included 3 prenatal visits, daily in-hospital support, and up to 11 postpartum home visits promoting EBF and addressing potential obesity-related breastfeeding barriers. Standard care involved routine access to breastfeeding support from hospital personnel, including staff peer counselors. Data collection included an in-hospital interview, medical record review, and monthly telephone calls through 6 months postpartum to assess infant feeding practices, demographics, and health outcomes. Bivariate and logistic regression analyses were conducted.
RESULTS:
The intervention had no impact on EBF or breastfeeding continuation at 1, 3, or 6 months postpartum. In adjusted posthoc analyses, at 2 weeks postpartum the intervention group had significantly greater odds of continuing any breastfeeding (adjusted odds ratio [aOR]: 3.76 [95% confidence interval (CI): 1.07–13.22]), and giving at least 50% of feedings as breast milk (aOR: 4.47 [95% CI: 1.38–14.5]), compared with controls. Infants in the intervention group had significantly lower odds of hospitalization during the first 6 months after birth (aOR: 0.24 [95% CI: 0.07–0.86]).
CONCLUSIONS:
In a Baby-Friendly hospital setting, SBFPC targeting overweight/obese women did not impact EBF practices but was associated with increased rates of any breastfeeding and breastfeeding intensity at 2 weeks postpartum and decreased rates of infant hospitalization in the first 6 months after birth.
doi:10.1542/peds.2012-0688
PMCID: PMC3529944  PMID: 23209111
breastfeeding; peer counseling; obesity; overweight; exclusive breastfeeding; hospitalization; breastfeeding self efficacy

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