This document discusses guidelines for breastfeeding in special cases such as HIV-positive mothers, mothers with tuberculosis or other illnesses, mothers who smoke or drink, and mothers with multiple births. It recommends that HIV-positive mothers exclusively breastfeed if they receive antiretroviral treatment, as this reduces transmission risk to below 2%. For mothers with tuberculosis, it recommends continuing exclusive breastfeeding while treating the mother with antibiotics. For other conditions, it evaluates risks and benefits of breastfeeding versus alternatives on a case-by-case basis. The overall message is that breastfeeding has significant benefits and can often continue safely in special cases by following evidence-based guidelines.

1. Breastfeeding& special cases
1. 1. Exclusive Breast Feeding In Special Cases… “Doc… Should I or Shouldn't I?” “Madam,
You Should or you Should not!”
2. 2. We Will Look Into Following Cases In Brief:  PLHA Mother  Mother with Active
Pulmonary Tuberculosis  Mother who fails to quit Smoking or/& Alcohol  Mother on Anti
cancerous Chemotherapy  Infant with Diarrhea  Infant with ARI  Multiple pregnancies 
Any other condition you want to think of?
3. 3. Mother: “Doc, should I breastfeed my baby, I am HIV+”? Without Non breast ARVs, HIV-
infected mothers have 10 to 15% chance of passing HIV through breast milk, and still lower if
on ARV feeders are at high risk of: Malnutrition, ARI, Diarrhea- All leading causes of deaths!
Baby may survive, only to suffer later in life from DM, Allergies, Au to- immune diseases
4. 4. Without ARVs <5% with ARV& guidelines <2% with ARV& guidelines
5. 5. Breastfeeding protects Especially the youngest infants IFE 1/4 Times more likely to die if
not breastfed Studies Quote infant mortality even up to 21% among normal population, w ho
are not breastfed! Age in months WHO Collaborative Study Team. Effects of breastfeeding
on infant and child mortality due to infectious disease in less developed countries: a pooled
analysis. The Lancet 2000;355:451-5 Risk of death if breastfed is equivalent to one.
6. 6. Risks of not breastfeeding Particular high risk of: Diarrhoea and ARTI Malnutrition Can
lead to: - Ill health - Poor development - Affect can last for life - DEATH Aceh
7. 7. Mother: “Doc, should I breastfeed my baby, I am HIV+”? Doc: “Madam, AFASS”
8. 8. For Person Living with HIV/AIDS  If Baby is HIV+ due to Prenatal Transmission  If Baby
is HIV-ve or  Baby’s status is not known  Advise Exclusive Breast feed, just as for a HIV-
ve mother Acceptable Feasibility  Work it out according to AFASS Safe Affordable
Sustainable
9. 9. So to summarize:  Ask for:  HIV status of the child  Viral load in the mother- higher the
maternal plasma HIV load (>3.7 log 10 copies/mL), higher the risk!  CD4 Count< 200/ ml 
Breast health  ARV therapy  Motivation& SE Status of the mother& family to Assess
AFASS  Whatever you advise the mother to do, do it exclusively
10. 10.  You, as doc decide according to (AFASS):  Breastfeed with ARV intervention or, 
Avoid All breastfeeding,  Continue ARV mother, compulsorily for  Start prophylactic ARV
for infant: Daily NVP un till 1 week after Stopping Breast feed, compulsorily  For non breast
feeders, Start prophylactic ARV for infant: Daily NVP till 4- 6 weeks of age, compulsorily
11. 11. Moral of the Story:  HIV+ Mothers should exclusively breastfeed their infants for the first
6 months of life, introducing appropriate complementary foods thereafter, and continue
breastfeeding for the first 12 months of life.  Mothers known to be HIV-infected who decide
to stop breastfeeding at any time should stop gradually within one month.  Infants should
continue prophylaxis for one week after breastfeeding is fully stopped.
12. 12.  Alternatives to breastfeeding include:  For infants less than six months of age: 
Commercial infant formula milk as long as AFASS is met,  Expressed, heat-treated breast
milk  NO to Home-modified animal milk in the first six months of life.  All children need
complementary foods from six months of age.
13. 13. There’s always a tug of war… In a Doc’s mind! Between 5% minus 2% & 21%
14. 14. Break a Myth Mixed feed is bad, so Is Abrupt Cessation of breast feeding good for the
baby of a HIV+ mother?...
15. 15. Break a Myth Mixed feed is bad, so Is Abrupt Cessation of breast feeding good for the
baby of a HIV+ mother?... NO
16. 16. Baby of a Mother with Active Pulmonary Tuberculosis  Continue exclusive breast
feeding till 6 months of age,& thereafter as in normal population.  Start ATT for mother
immediately… Mother will be non infective within 2 months of regular ATT  Preventive
Chemotherapy for baby- INH 5mg/kg/day* 6 months  Use face mask while around the baby,

2. till 2 months after starting ATT  BCG Vaccine at birth… Something is better than Nothing! 
Re- immunize with BCG after stopping Preventive Chemotherapy
17. 17. Remember, its not only mother, Anybody (with TB) around can infect the baby with
Tuberculosis!
18. 18. Break a Myth Is ATT drug concentration in breast milk sufficient for the baby?...
19. 19. Break a Myth Is ATT drug concentration in breast milk sufficient for the baby?... NO
20. 20. Baby of a Mother who fails to quit smoking/ alcohol!!  QUIT SMOKING & ALCOHOL! 
It is better to exclusively breast feed the baby than to top feed her even if her mother
smokes!  Breast milk does pass nicotine to the baby, but more harm happens due to
passive smoking& the smoke dust which invisibly “clings” to your body, hands, clothes, hair&
even beddings!  Remember, Anybody smoking in the house would leave the smoke dust to
harm the baby
21. 21. Baby of a Mother who fails to quit smoking/ alcohol!!  Alcohol passes freely into
mother's milk & peaks about 30 to 60 minutes after consumption, 60 to 90 minutes when
taken with food.  Avoid breast-feeding until alcohol has completely cleared breast milk. This
typically hrs, depending on your body weight. takes 2-3  So, If you plan to drink alcohol,
consider having a drink just after breast-feeding so that the alcohol begins to clear your
breast milk during the natural interval between breast-feeding sessions.  Remember,
infant’s hepatic system is immature till 2- 3 months age, even small amounts of alcohol can
be detrimental!
22. 22. Break a Myth Does Pumping and dumping breast milk speed the elimination of alcohol
from your body…
23. 23. Break a Myth Does Pumping and dumping breast milk speed the elimination of alcohol
from your body... NO
24. 24. Breast feeding multiple pregnancies  Do Not put off breastfeeding because you're
having multiple babies.  It's possible to breastfeed twins and even triplets. Many are
breastfed until they are weaned.  Multiple babies are more likely to be born prematurely, so
there are even more benefits to breastfeeding.  Breast milk is better for premature babies
as their gut is immature and it's easier for them to tolerate and digest
25. 25. Break a Myth Will there be a “lack of milk”, if there are multiple babies born?...
26. 26. Break a Myth Will there be a “lack of milk”, if there multiple babies are born?... NO
27. 27. Thank you!