Feature
Making BREASTFEEDING SAFE By Kelly Mills
Public Health
11
Feature
Mothers with HIV run the risk of transmitting the virus to their children through breastfeeding. Now researchers at the School have developed a low-tech method for heat-treating breast milk that will minimize the risk of infection and save lives. Mothers in the developing world who are infected with HIV face a terrible dilemma. The virus can be transmitted from mother to infant through breast milk; in fact, about 200,000 to 350,000 infants each year become infected with HIV through breastfeeding alone, and 90 percent of these cases are in sub-Saharan Africa. While HIV-positive mothers in industrialized nations are advised to feed their babies with formula, this is often not a viable option for mothers in the developing world, who may not have regular access to formula or cannot afford it. Even more problematic is the fact that these mothers may not have safe water to mix with the formula. Another consideration is that formula-fed infants are deprived of the natural immunities that breast milk can provide. In fact, infant mortality for non-breastfed babies in Ghana, India, and Peru is ten times that of breastfed infants. This problem caught the attention of Kiersten Israel-Ballard, currently working toward her doctorate in public health, when she was an M.P.H. student in infectious diseases at the School. Israel-Ballard noted that since 12
University of California, Berkeley
1 Breast milk can be heat-treated with only a jar, water, and a charcoal stove. 2 Kiersten Israel-Ballard (right) works with project volunteer Helen Mtubatuba in her home in Zimbabwe. 3 Israel-Ballard collects breast milk from healthy women and "spikes" it with highly infectious concentrations of HIV in the lab to determine whether or not heat treatment will kill the virus.
1
2
at least 1998, the World Health Organization (WHO) guidelines recommended that HIV-positive mothers breastfeed exclusively for the first months of an infant’s life, then wean the infant and switch to an alternative food source. However, this had tremendous problems in practical application, as mothers often lacked a consistent alternative food supply. Abruptly stopping nursing also causes the virus to accumulate in the breast milk, so if a mother did return to
breastfeeding, even infrequently, the risk of transmission was increased. Infants who were abruptly weaned began to show a high rate of malnutrition and a host of related diseases since they were not getting the immune protection of breast milk. The WHO guidelines also mentioned pasteurization, or heat-treating the milk as a possible method of killing the virus and making the milk safe. However, Israel-Ballard was unable to find significant studies to support this
Feature
3
While HIV-positive mothers in industrialized nations are advised to feed their babies with formula, this is often not a viable option for mothers in the developing world, who may not have regular access to formula or cannot afford it. recommendation. She also realized that nobody had asked the mothers if they would be willing to use heat treatment of milk. She began to wonder if this recommendation was a viable option for mothers in the developing world. As a student in the School’s Dr.P.H. Program, Israel-Ballard has conducted studies on heat-treating breast milk along with School of Public Health professor Barbara Abrams and pediatrician and principal investigator Caroline Chantry from UC Davis Medical Center. They found that, in fact, the virus can be made inactive through a simple, low-tech method of flash-heating using the most basic of
materials—a tin pan, an empty peanut butter jar, and water—to quickly heat the milk, while allowing it to retain its vital antibodies, proteins, and vitamins. By having mothers hand-express milk, then put it in the jar, place it in a pan of water, and bring it to a boil, the milk is pasteurized and can even be stored without refrigeration for a few hours. But would mothers in the developing world be willing and able to treat their milk? As one of the first steps in the study, Israel-Ballard, Abrams, and Chantry addressed the acceptability of this method. They conducted focus groups with HIV-positive mothers in Zimbabwe, and they were surprised
to learn that mothers would be willing to heat treat milk and were also supportive of the flash-heating method. Now Israel-Ballard, Chantry, and Anna Coutsoudis, a renowned international pediatric HIV researcher at the University of KwaZulu-Natal in Durban, South Africa, are beginning research to determine how much support—such as a weekly visit from a counselor—would enable mothers to consistently practice the heat treatment. The next study is being planned in Tanzania. When Abrams, Chantry, and IsraelBallard presented these results at the International AIDS Conference last summer, it brought a new, sudden attention to the subject. “The WHO is now calling for randomized control trials on heat treatment,” says IsraelBallard. “When we began this work we could barely get funding.”
Public Health
13