Infant feeding within the context of HIV

Thumbnail Image
Janse van Rensburg, Liska
Journal Title
Journal ISSN
Volume Title
University of the Free State
English: The potential problems that HIV (human immunodeficiency virus) and AIDS (acquired immune deficiency syndrome) cause are multifaceted and can have devastating effects on a community. These problems are closely related to issues such as unemployment, poverty and co-morbidities. Another dilemma that is created by HIV involves the feeding of infants born to HIV-infected women, and it is especially the poor who experience the burden of this predicament. In an ideal setting where resources are reliably available, it is recommended that HIV-infected mothers do not breastfeed as the risk of postnatal HIV transmission remains. The use of anti-retroviral medications can however, significantly decrease this risk. In resource-poor areas, such as in many South African communities, mothers are generally recommended to breastfeed. In these circumstances the safe and sustainable procurement and preparation of replacement feeds cannot be assured. It has been shown that the incorrect preparation of formula milk or the use of unsuitable breastmilk substitutes can notably increase infant mortality and morbidity, while breastfeeding has a major protective effect. Each HIV-infected pregnant woman must therefore weigh these options and attempt to make the best decision for her unique situation. Good quality counseling from health care workers is imperative to aid her in this process. The purpose of this cross-sectional descriptive study was to investigate the knowledge, attitudes and practices of health care workers (n = 64) in the maternity wards of Pelonomi Regional Hospital in the Free State regarding infant feeding in the context of HIV. This was also determined in HIV-infected mothers (n = 100) who had recently given birth at the same health care institution. The knowledge, attitudes and practices of health care workers were determined by means of self-administered questionnaires. The researcher completed the following questionnaires with the HIV-infected mothers during private structured interviews: socio-demography; household food security; anthropometry (infant / infants), reported health and medical histories (including infant / infants); knowledge, attitudes and practices regarding HIV and infant feeding; and, questions based on the 2010 WHO (World Health Organisation) Guidelines on HIV and Infant Feeding. Information that was obtained from patient files included in-hospital medication, CD4 cell counts and haemoglobin levels of mothers, as well as birth weight and birth length of infants. The over-all level of knowledge of the health care workers related to infant feeding in the context of HIV was not adequate, when it is considered that they interact with and counsel HIV-infected women on a daily basis and should be very well-informed regarding all of the related issues. Few of them could comprehensively explain what ‘exclusive breastfeeding’ entails (6.7%). Many felt that they lacked practical knowledge related to breastfeeding, as 25.6% felt that they only had low to moderate confidence in showing a mother how to breastfeed, and 35.9% felt that they only had low to moderate confidence in showing a mother how to express breastmilk. However, most of the health care workers (89.1%) had a positive attitude towards South Africa promoting breastfeeding for infants of HIV-infected mothers if they cannot safely and sustainably procure formula milk. Most of the mothers participating in this study were black, unmarried, unemployed and Sotho-speaking. Although most mothers lived in brick houses (84.0%) with access to electricity (83.0%) and tap water (96.0%), a large percentage of mothers indicated that food and money shortages do occur in their households (64.0%). However, very few mothers reported that they had a vegetable garden (23.0%) or owned livestock (4.0%). Some of the mothers experienced symptoms such as chest pain (16.0%), diarrhoea (18.0%), loss of appetite (36.0%) and involuntary weight loss (11.0%). Hypertension was common in both mothers (26.0%) and their family members (42.0%). A large percentage of mothers had a relatively low (< 350 cells/mm3) CD4 count (46.3%), and a low (< 11.0 g/dL) haemoglobin level (37.3%), indicators of HIV disease progression and anaemia respectively. Approximately 25.0% of infants were classified as premature according to the WHO definition, and most mothers planned to breastfeed their infant/s (70.9%). The median z-scores for the length-for-age parameter in the full-term group (n = 75) was in the normal category, while the weight-for-age and weight-for-length parameters in the full-term group were slightly below the WHO median reference values. Twenty-six breastfeeding problems were reported in total, with low milk production (38.5%) and sore breasts and nipples (46.2%) the main breastfeeding problems that were experienced. Most mothers correctly planned to wean their infants at six months, with the median value for the introduction of both solids and liquids being six months. The majority lacked adequate knowledge regarding general correct formula feeding practices, and when mothers decided on formula feeding it was mainly done in an attempt to prevent postnatal HIV transmission (76.7%). A large percentage of the mothers were not aware of the fact that HIV can be transmitted to an infant via breastfeeding (43.0%) even when anti-retroviral medications are used. They knew that HIV-infected breastfeeding mothers should not practice mixed feeding (80.0%), but they lacked knowledge related to the new WHO guidelines. As AFASS (affordable, feasible, acceptable, sustainable, safe) criteria for formula feeding were not met by most mothers, a large percentage of mothers correctly opted to breastfeed their infants. Almost all of the mothers regarded animal milks such as cow’s milk as the least preferable infant feeding option (83.0%). In general, counseling that mothers had received was not adequate, or information was not retained by the mothers, since certain concepts related to HIV and infant feeding could mostly not be described sufficiently. Only 16.7% of mothers who chose to formula feed could comprehensively explain the correct procedure. Mothers were mostly either ignorant or skeptical regarding expressed heat-treated breastmilk as an infant feeding option (78.0%). Nursing personnel were significantly more accepting of heat-treated expressed breastmilk as an infant feeding method than the doctors and dieticians group combined (53.2% and 23.5% respectively), and they also felt a higher confidence in showing a mother how to breastfeed (78.7 % and 58.8% respectively). The age of the mothers did not influence their knowledge related to HIV and infant feeding significantly. Mothers with higher educational levels were significantly more aware that HIV can be transmitted via breastfeeding and they were also more concerned about transmitting HIV via breastfeeding than they were of the increased morbidity and mortality risks related to replacement feeding. The provision of high quality counselling related to infant feeding and follow-up visits can improve the knowledge of HIV-infected mothers and lead to better infant feeding decisions being made. These actions will ultimately benefit both the mother and her infant.
Afrikaans: Die potensiële probleme wat MIV (menslike immuniteitsgebrekvirus) en VIGS (verworwe immuniteitsgebrekvirus) veroorsaak, is veelvuldig en het verwoestende gevolge in ‘n gemeenskap. Hierdie probleme hou nou verband met werkloosheid, armoede en verwante morbiditeite. Nog ’n dilemma van MIV is die voeding van die babas van MIV-geïnfekteerde moeders met veral die armes wat die las van hierdie verknorsing ondervind. In 'n ideale omgewing waar hulpbronne betroubaar beskikbaar is, word aanbeveel dat MIV-geïnfekteerde moeders nie borsvoed nie as gevolg van die risiko vir MIV oordrag na geboorte. Die gebruik van antiretrovirale middels kan hierdie risiko merkwaardig verlaag. In hulpbron-arm gebiede, soos in baie Suid-Afrikaanse gemeenskappe, word daar algemeen vir moeders aanbeveel om te borsvoed. In hierdie gevalle kan dit nie verseker word dat die gebruik van plaasvervanger voedings, in die vorm van die formule melk, op 'n veilige en volhoubare manier voorberei sal kan word nie. Daar is bewys dat die verkeerde voorbereiding van formule melk of die gebruik van nie-geskikte borsmelk vervangers, infantiele mortaliteit en morbiditeit verhoog, terwyl borsvoeding 'n belangrike beskermende effek uitoefen. Elke MIV-geïnfekteerde swanger vrou moet dus hierdie opsies opweeg en probeer om die beste besluit vir haar unieke situasie te maak. Goeie kwaliteit berading deur die gesondheidsorgwerkers is noodsaaklik om haar in hierdie proses te help. Die doel van hierdie dwarssnit-beskrywende studie was om ondersoek in te stel na die kennis, houdings en praktyke van gesondheidsorgwerkers (n = 64) in die kraamsale van die Pelonomi Streekshospitaal in die Vrystaat ten opsigte van babavoeding in die konteks van MIV. Dit is ook in MIV-geïnfekteerde moeders (n = 100) wat onlangs geboorte by dieselfde gesondheidsorginstansie geskenk het, bepaal. Die kennis, houdings en praktyke van gesondheidsorgwerkers is met gebruik ‘n van self-geadministreerde vraelys bepaal. Die navorser het die volgende vraelyste vir die MIV-geïnfekteerde moeders gedurende private gestruktureerde onderhoude voltooi: sosio-demografie; huishoudelike voedselsekuriteit; antropometrie (baba / babas); gerapporteerde gesondheids-en mediese geskiedenis (insluitende baba / babas); kennis, houdings en praktyke ten opsigte van MIV en babavoeding; asook vrae wat op die 2010 WGO (Wêreld Gesondheid Organisasie) Riglyne vir MIV en Babavoeding gebaseer is. Inligting wat van pasiëntlêers verkry is, het die volgende ingesluit: medikasie tydens hospitalisasie; CD4-seltellings en hemoglobienvlakke van die moeders; asook die geboortemassas en geboorte lengtes van die babas. Die algehele vlak van kennis van die gesondheidsorgwerkers in verband met babavoeding in die konteks van MIV was nie voldoende nie, veral indien dit in ag geneem word dat hulle op 'n daaglikse basis met MIV-geïnfekteerde moeders kommunikeer asook raad verskaf, en moet dus uiters goed oor al die verwante kwessies ingelig wees. Die minderheid van die gesondheidsorgwerkers kon presies verduidelik wat 'eksklusiewe borsvoeding’ behels (6.7%). ‘n Groot proporsie het gevoel dat hulle ‘n gebrek aan praktiese kennis met betrekking tot borsvoeding het, aangesien 25.6% gevoel het dat hul slegs ‘n lae tot matige vlak van selfvertroue het om ‘n ma te wys hoe om te borsvoed, en 35.9% het gevoel dat hul slegs ‘n lae tot matige vlak van selfvertroue het om ‘n ma te wys hoe om borsmelk uit te melk. Die meeste gesondheidsorgwerkers (89.1%) het 'n positiewe houding teenoor Suid-Afrika se bevordering van borsvoeding vir babas van MIV-geïnfekteerde moeders gehad, indien moeders nie op ‘n veilige en volhoubare wyse formule melk aan hulle babas kan verskaf nie. Die meeste moeders wat aan die studie deelgeneem het was swart, ongetroud, werkloos en Sotho-sprekend. Alhoewel die meeste moeders in baksteenhuise (84.0%) met toegang tot elektrisiteit (83.0%) en kraanwater (96.0%) bly, het 'n groot persentasie van die moeders aangedui dat voedsel-en geldtekorte tog in hul huishoudings voorkom (64.0%). Baie min moeders het egter gerapporteer dat hulle 'n groentetuin (23.0%) besit of vee aanhou (4.0%). Sommige moeders het simptome soos borspyn (16.0%), diarree (18.0%), aptytverlies (36.0%) en onwillekeurige massaverlies (11.0%) ervaar. Hipertensie was algemeen in beide die moeders (26.0%) asook hul familie lede (42.0%). ‘n Groot persentasie moeders het relatiewe lae (< 350 cells/mm3) CD4-tellings (46.3%) en lae (< 11.0 g/dL) hemoglobienvlakke (37.3%) gehad, wat onderskeidelik MIV-siekte progressie en anemie aandui. Ongeveer 25.0% van die babas was as prematuur volgens die WGO se definisie geklassifiseer, en die meeste moeders het beplan om hul babas te borsvoed (70.9%). Ses-en-twintig borsvoedingsprobleme is in totaal gerapporteer, met lae melkproduksie (38.5%) en seer borste en tepels (46.2%) aangedui as die hoof borsvoedingprobleme wat ondervind was. Die meeste moeders het korrek beplan om hul babas op ses maande te speen, met die mediaanwaarde van beide die bekendstelling van vaste voedsels en vloeistowwe, as ses maande. Die meerderheid het nie voldoende kennis ten opsigte van korrekte formule voeding gehad nie, en wanneer moeders wel op formule voeding besluit het, is dit hoofsaaklik gedoen in 'n poging om MIV-oordrag na geboorte te voorkom (76.7%). ‘n Groot persentasie moeders was nie bewus van die feit dat MIV na 'n baba deur middel van borsvoeding oorgedra kan word nie, selfs wanneer antiretrovirale middels gebruik word (43.0%). Moeders het geweet dat MIV-geïnfekteerde borsvoedende moeders nie gemengde voeding (‘mixed feeding’) moet beoefen nie (80.0%), maar het gebrek aan kennis met betrekking tot die nuwe WGO-riglyne getoon. Aangesien die meeste moeders nie aan die AFASS (‘affordable, feasible, acceptable, sustainable, safe’) kriteria vir formule voeding voldoen het nie, het 'n groot persentasie van die moeders korrek gekies om hul babas te borsvoed. Byna al die moeders (83.0%) het diere melk, soos byvoorbeeld koeimelk, as die minste geskik vir babavoeding beskou. Oor die algemeen was die berading wat moeders ontvang het nie voldoende nie, of die inligting is nie deur moeders onthou nie, aangesien sekere konsepte wat met MIV en babavoeding verband hou, meestal nie voldoende beskryf kon word nie. Moeders wat verkies het om hulle babas met formule melk te voed kon oor die algemeen nie volledig verduidelik hoe om dit korrek te doen nie, aangesien slegs 16.7% wel dit kon doen. Hulle was ook óf oningelig óf skepties oor hitte-behandelde borsmelk as 'n babavoedingopsie (78.0%). Verpleegpersoneel het aansienlik meer aanvaarding vir hitte-behandelde borsmelk as 'n babavoedingopsie as die groep dokter en dieetkundige groep getoon (53.2% en 23.5% onderskeidelik), en hul het ook gevoel dat hul meer selfvertroue het om 'n moeder te wys hoe om te borsvoed (78.7% en 58.8% onderskeidelik). Die ouderdom van moeders het nie hul se kennis met betrekking tot MIV en babavoeding beduidend beïnvloed nie. Moeders met 'n hoër opleidingsvlak was aansienlik meer bewus van die feit dat MIV deur middel van borsvoeding oorgedra kan word, en hul was banger vir die oordrag van MIV via borsvoeding as die verhoogde morbiditeit en mortaliteit risiko's wat met formule voeding verband hou. Die voorsiening van hoë gehalte berading ten opsigte van babavoeding asook opvolgbesoeke kan die kennis van MIV-geïnfekteerde moeders verbeter wat tot beter babavoedingbesluite kan lei. Hierdie aksies sal uiteindelik beide die moeder en haar baba bevoordeel.
Dissertation (M.Sc.(Dietetics) (Nutrition and Dietetics))--University of the Free State, 2013, Nutrition disorders in infants, HIV infections -- Nutritional aspects, Infants -- Nutrition, AIDS (Disease) in infants -- Nutritional aspects, Infants -- Nutrition -- Requirements