The document discusses breastfeeding among HIV positive mothers. It provides 3 main options for infant feeding: 1) replacement feeding with commercial infant formula, 2) replacement feeding with home modified animal milk, and 3) exclusive breastfeeding for the first six months. It outlines the benefits and risks of each option. It also discusses the role of healthcare providers in counseling HIV positive mothers on infant feeding choices and supporting them.

1. Breastfeeding among HIV
positive or HIV unknown
mother
Prepared by:
Kalpana kawan
BNS 2nd year
Roll no. 06

2. General objective
• At the end of session, the Bsc Nursing 3rd year student's will be able
to explain about 'breastfeeding among HIV positive or HIV unknown
mothers. '

3. Specific objectives
• Benifits and risk of replacement feeding with commercial infants
formula.
• Benifits and risk of replacement feeding with home modified animal
milk.
• Benefits of exclusive breastfeeding for the first six months in HIV
positive mother
• Role of the health care provider in counselling an HIV positive mother

4. Options 4: Replacement feeding with
commercial infant formula

5. Options 4: Replacement feeding with
commercial infant formula
-The infant is feed commercial infant formula from birth ( no
breastfeeding )
Benefits:
• Giving only formula carries no risk of transmitting HIV to the baby.
• Most of the nutrients the baby needs have already been added to
the formula.
• Other responsible family members can help feed the baby , if mother
fall ill, sickness.

6. Contd.....
Risks or Disadvantages:
• Safe replacement feeding requires:
A reliable and affordable supply of the selected replacement food
and a safe place to store it.
Nutritionally adequate commercial infant formula or home modified
animal milk.
Clean water to prepare the replacement food.
Clean utensils.

7. Contd.........
Adequate supply of fuel.
Good hygiene and good sanitation.
Time to prepare and feed the infant the replacement food.
Knowledge and the ability to read instruction the selected infant
formula package.

8. Contd.....
• Unlike breastmilk, formula milk does not contain antibodies that
protect the baby from infections.
• Formula fed baby is more likely to get seriously sick from diarrhoea,
chest infections, and malnutrition, especially if the formula is not
prepared correctly.
• Mother must stop breastfeeding completely or the risk of
transmitting HIV will continue.

9. Contd.......
• Formula milk is expensive and must always have enough money on
hand.
• Formula milk takes time to prepare and must be made fresh for each
feed(unless you have a refrigeretor)
• The baby will need to drink from a cup.

10. Contd..
• People may wonder why the mother is using formula instead of
breastfeeding, and this could cause them to suspect the mother is
HIV positive.
• Mother may get pregnant again too soon.

11. Options 5 : Replacement feeding with home
modified animal milk

12. Options 5 : Replacement feeding with home
modified animal milk
• The infant is feed appropriately modified animal milk from birth( no
breastfeeding)
Benefits of replacement feeding
• No risk of HIV transmission through feeding. ( There is still a chance
that the baby may have acquired HIV infection during pregnancy or
birth)

13. Contd.........
• Home modified animal milk may be cheaper than commercial infant
formula and is easily available if you have milk producing animals.
• Mother and baby can seperated. Infant feeding is not interrupted if
the mother is sick or dies.
• Other people besides the mother can help feed the baby.
• The baby can become closely attached to other people besides the
mother.

14. Contd...
Risks or Disadvantages of replacement feeding
• Animal milk is hard for babies to digest and does not contain all the
nutrients that babies need.
• Both fresh and processed milk need to be mixed with water and
sugar in exactly the right amounts. Baby also needs to have a
micronutrient supplement.
• Breast milk substitutes lack anti infective antibodies.

15. Contd....
• Breast milk substitutes lack growth hormones.
• Purchase of enough breast milk substitutes to feed an infant can
consume a large portion of the family's income.
• Improper preparation of breast milk substitutes can cause diarrhoel
disease and/or malnutrition.

16. Contd
• Women who do not breastfeed lose the child spacing benefits of
breastfeeding and need access to affordable and appropriate family
planning services.
• Infants who do not breastfeed may not get adequate psychosocial
stimulation and may not bond well with their mothers.

17. Benefits of exclusive breastfeeding for the first
six months in HIV positive mother
• The World Health Organization (WHO) recommends that HIV-infected
mothers breastfeed exclusively for the first 6 months of life and
continue breastfeeding for at least 12 months, with the addition of
complementary foods. These mothers should be given ART to reduce
the risk of transmission through breastfeeding.
• The new evidence means that mothers living with HIV and their
children can benefit from the many advantages of breastfeeding –
such as improved growth and development – in the same way as
mothers who do not have HIV and their children.

18. Contd..
• Exclusive breastfeeding reduces the risk of postpartum transmission
of HIV from an infected mother to her baby. Non-exclusive
breastfeeding, on the other hand, more than doubles the risk of
vertical transmission of HIV .
• Breast milk is complete food for infants and provides ideal nutrition
for babies
• Breastmilk is first immunization. It make the immune system
stronger.

19. Contd....
• Breastmilk gives all of the nutritions and water they need. So
breastfeed babies do not need any other liquid or feed.
• Breast milk is free, always available, and does not need any special
preparation.
• The mother gives all the benefits of breastfeeding during the critical
early months of life (best food for baby, protection from infection,
supports best growth and development)

20. Contd....
• Breast milk is the perfect food for babies and protects from many
diseases, especially diarrhoea and pneumonia and the risk of dying
from these diseases.
• It contains important antibodies ,IgA , which can help prevent or fight
illness in baby.
• Some studies suggest there may be a difference in brain development
between exclusive breastfeed and formula-feed babies.

21. Contd.
• Breastfeeding helps in the proper involution of the uterus after
childbirth.
• Exclusive breastfeeding helps in natural contraception by pausing the
menstruation and ovulation.

22. Lets refresh

23. Role of the health care provider in counselling
an HIV positive mother
Give special counseling to HIV positive mother who chooses
breastfeed
• For the mother living with HIV , simple message is " once ARV
started, it is taken for life" to reduce HIV transmission through
breastfeeding in accordance with WHO recommendations.
• Support the mother's choice as shorter duration of breastfeeding at
least of less than 12 months are better than never initiating
breastfeeding at all.

24. Contd...
• All pregnant women with HIV who are on ART are recommended to
continue breastfeeding as per the national breastfeeding protocal.
• Advice mothers living with HIV should breastfeed for at least 12
months and may continue breastfeed for up to 24 months or longer
(similar to general population ) while being fully supported for ART
adherence.

25. Contd....
• Encourage mother for exclusive breastfeeding

26. Contd.......
• Advice the mother against mixed feeding.
+ +

27. Contd......
Encourage mother to breastfeed as often as the baby wants and for
as long as the baby wants.(demand feeding).

28. Contd....
• Ensure correct positioning

29. Contd....
Ensure good attachment

30. Contd.........
Explained that good positioning and attachment help to prevent mastitis
and damage to the mother's nipples

31. Contd....
• Advise the mother to return immediately if she has any problems
with her breasts or nipples, or if the baby has any difficulty feeding.
• During breast infection (especially mastitis) and cracked or bloody
nipples, suggested to avoid breastfeeding until complete cure or give
expressed breast milk.

32. Contd.
• If there are no other problems requiring hospitalization, discharge the
baby.
• Ensure a follow up visit during the first week after discharge to
attachment and positioning and the condition of the mother's
breasts.
• Ensure that the baby receives regular follow up visits with an
appropriate child care provider.

33. Contd.......
 Arrange the further counseling to prepare the mother for the
possibility of stopping breastfeeding early.
If baby is approaching six months, discuss the possibility of stopping
breastfeeding early.

34. Contd......
Following the period of exclusive breastfeeding for 6 month,
suggested HIV - infected women to cease breastfeeding completely.
Breastfeeding should only stop once a nutritionally adequate and
safe diet without breast milk can be provided or at 6 month when
exclusive breast feeding is not adequate to meet an infant's
nutritional need.

35. Contd.....
• Early cessation of breastfeeding may induce undernutrition if another
milk source is not available, which in turn could enhance morbidity
compared to those children who breastfeed for longer period.
• Early cessation of breastfeeding before 6 month was associated with
an increased risk of infants morbidity ( diarrhoea) and mortality in
HIV exposed children.

36. Contd......
• Breast milk viral load is substantially higher after rapid cessation and
this may poses an increased risk of HIV transmision if children
resume breastfeeding after a period of cessation.
• While you are breastfeeding, teach your baby to drink expressed,
unheated breat milk from a cup.
• This milk may be heat-treated to destroy the HIV.

37. Contd..
• Once the baby is drinking comfortably, replace one breastfeed with
cup feed using expressed breast milk.
• Encourage mother to use cup feeding beacuse it is better than a
bottle and better than a cup and spoon.

38. Contd.........
• Increase the frequency of cup feeding every few days and reduce the
frequency of breastfeeding.
• Ask an adult family member to help cup feed the baby.
• Stop putting the baby to the breast completely as soon as you and
your baby are familiar to frequent cup feeding.

39. Contd......
• If baby is only receiving milk, check that your baby is passing enough
urine at least 6 wet diapers in every 24 hours period. This mean that
he/she is getting enough milk.
• Gradually replace the expressed breast milk with formula or home
modified animal milk.
• If your baby needs to suck, give him/her one of your clean fingers
instead of the breast.

40. Contd..........
• To avoid breast engorgement (swelling) express a little milk
whenever breast feel too full. This will help you to feel more
comfortable. Use cold compresses to reduce the inflammation.Wear
a firm bra to prevent breast discomfort.

41. Contd..
• Do not begin breastfeeding again once you have stopped. If you do,
you can increase the chances of passing HIV to baby.
• Begin using the family planning method of your choice, if you have
not already done so, as sson as you start reducing breastfeeds.

42. Contd.........
Give special counseling to HIV positive mother who chooses
replacement feeding
• Support the mother's choice.
• Ensure that the mother is not breastfeeding and is using a suitable
type of replacement milk.

43. Contd.........
• Ensure that the mother understands that if she chooses replacement
feeding, she should begin complementary feeding at six months of
age while continuing to provide milk.
• Allow the mother to begin preparing the replacement feed as soon
as she is able to and teach her how to feed the baby using a cup, cup
and spoon, or other device (eg. paladai).

44. Contd.........
• Encourage the mother to feed the baby at least 8 times daily. Teach
her to be flexible and respond to the baby's demands.
• Explain the risks of replacement feeding and how to avoid them:
• The baby may get diarrhea, malnutrition, and other infection. If the
mother's hands, water, or utensils are not clean, or if the milk stands
too long before being used;

45. Contd.......
• The baby may not grow well if:
too little substitute is given at each feed;
too few feeds are given
the substitute contains too much water
the baby has diarrhea

46. Contd.......
• Advice the mother to seek care if the baby has any problems, such
as:
feeding less than six times daily or taking smaller quantities;
Diarrhea
Poor weight gain.
• Ensure that the baby receives regular follow up visits with an
appropriate child car provider.

48. Post test

49. Write 'T' for True and 'F' for false in the box for following statement.
(1X5= 5)
1) Animal milk is easy for babies to digest .
2) Improper preparation of breast milk substitutes can
cause diarrheal disease and/or malnutrition.
3) Exclusive breastfeeding does not helps in natural contraception.
F
T
F

50. Contd......
4)Encourage mother for mix feeding to decrease the risk of HIV
transmission.
5) Exclusive breastfeeding means giving only breast milk and no other
drinks or foods, not even water , with the exception of drops or syrups
consisting of vitamins, mineral supplements, or medicines to the baby.
F
T

51. Summary

52. Home assignment:
• Read about Role of the health care provider in counselling an HIV
positive mother

53. Plan for next class:
• We will discuss about Post exposure prophylaxis with ARVs for the
HIV exposed infant and HIV testing in infants.

54. References
• Prasai( Subedi) D.,"Textbook of Midwifery Nursing(Postpartum
care)part III",Akshav Publication,Kathmandu, 1st edition,2018,page
no. 190-195.
• Prasai (Subedi)D,"Textbook of midwifery Nursing Part I"Medhavi
publication,Jamal,Kantipath,Kathmandu,3rd edition,Jan 2016, Page
no. 502-511.
• Awasthi Sherpa M." Essential Textbook of MIdwifery Nursing Part I"
Samiksha Publication Pvt.Ltd. 1st edition 2074,page no. 354- 356.

55. • Tuitui R." Manual of Midwifery-C (postnatal)",Vidyarthi Pustak
Bhandar,bhotahity, kathmandu,10th edition,2014,page no.110- 115
• Retrived from https://who.int on 2977/07/28
• Retrived from www.unicef.org on 2077/07/28
• Retrived from
https://www.who.int/elena/titles/hiv_infant_feeding/en/#:~:text=Mo
thers%20living%20with%20HIV%20should,for%20treating%20and%2
0preventing%20HIV on 2077/08/05
• Retrive from
https://www.who.int/nutrition/publications/hivaids/guideline_hiv_inf
antfeeding_2016/en/ 2077/08/05