Marcia Frellick

September 21, 2017

CHICAGO — A controversy being debated around the world — whether women living with HIV should breast-feed — was in the spotlight here at the American Academy of Pediatrics 2017 National Conference and Exhibition.

The risk for transmission of the virus from mother to child is only about 1% in women treated with antiretroviral therapy during pregnancy, but that is "not zero," said Ellen Chadwick, MD, from the Feinberg School of Medicine in Chicago, who is chair of the AAP committee on pediatric AIDS.

Because clean water and alternatives to breast milk are widely available and affordable in the United States, that is not a risk worth taking, she said.

But not everyone agrees.

The risk for transmission is so low that it might be outweighed by the benefits of breast-feeding, said Robert Lawrence, MD, from the University of Florida Health in Gainesville, who is a member of the Academy of Breastfeeding Medicine. In addition, formula is associated with increased infant morbidity, he pointed out.

Different countries and organizations have taken different positions on the issue.

Benefits and Risks

The United Kingdom has come out strongly against breast-feeding for mothers with HIV, and Canada recommends exclusive formula feeding.

"Interestingly, Switzerland is considering updating its guidelines to allow breast-feeding by mothers who are being treated, have a suppressed viral load, and who are followed closely," Dr Chadwick reported.

The World Health Organization (WHO) recommends that mothers with HIV breast-feed for at least 12 months, and continue breast-feeding for up to 24 months if they are fully adherent to antiretroviral therapy.

However, the WHO guideline "is intended for countries with high HIV prevalence and countries where diarrhea, pneumonia, and undernutrition are common causes of infant and child mortality," Dr Chadwick explained. "This is a very different scenario than we have in the United States."

For women with HIV who are not being treated, breast-feeding is a significant source of transmission. In fact, for women not on antiretroviral therapy who breast-feed from 6 to 20 months, the risk for transmission is 4% to 22%, she reported.

But, she added, it is important to have open and honest conversations about the mother's wishes without being heavy-handed.

"If you say, 'you can't breast-feed,' that shuts down conversation and you've lost your opportunity to educate," she explained. "The big problem there is that the mother will say, 'I just won't tell my doctor'."

The importance of open conversations was also emphasized by Dr Lawrence.

We really want to provide mothers with choice.

"We really want to provide mothers with choice," he said. "We need to consider whether the mom has a very good history of viral load control and very good support within her family and community. Then we can have an informed discussion and give her different alternatives."

And there are some downsides of formula feeding, including an elevated risk for infection in the first year of life, and for diabetes, sudden infant death syndrome, and childhood cancers, he pointed out.

In addition, studies have shown that the relative risk for breast cancer increases substantially in mothers who have never breast-fed, he added.

Optimal compliance — 90% breast-feeding in the first 6 months of life — could save $13 billion per year in healthcare costs in the United States and prevent more than 900 deaths, according to one study (Pediatrics. 2010;125:e1048-1056).

Conversations and Clean Water Vital

Pediatricians are key educators in the discussion about choices with a mother, and conversations are essential in any country, said moderator Rani Gereige, MD, from Nicklaus Children's Hospital in Miami.

In the United States, pediatricians should determine the intentions of an HIV-positive mother and, if she plans to breast-feed, she should be discouraged, he told Medscape Medical News.

Clean water is available for formula in the United States, as are programs that make alternatives affordable, such as the Women, Infants and Children nutrition service, he explained. And banked milk, which offers safer breast-feeding for mothers living with HIV, is also readily available.

But "in resource-poor countries, breast-feeding may be protective if the mom is taking her medication and has a low viral load and the risk of transmission is low," Dr Gereige added. "Breast milk will protect from infections, and the alternative is using water that isn't clean to make formula."

Dr Lawrence is a medical consultant for Prolacta. Dr Chadwick and Dr Gereige have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition. Presented September 19, 2017.

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