Bacterial contamination and over-dilution of commercial infant formula prepared by HIV-infected mothers in a Prevention of Mother-to-Child Transmission (PMTCT) Programme, South Africa.

To examine the safety of formula feeds used by mothers participating in a Prevention of Mother-to-Child Transmission (PMTCT) programme, contents of 94 feeding bottles collected at a PMTCT-clinic were analysed. An additional 17 samples were taken from already prepared feeds during home visits, as well as 21 samples from bottles prepared under observation. Living conditions and educational levels were overall good and mothers had been counselled on safe formula preparation. Samples were analysed for faecal bacteria, using Escherichia coli and Enterococcus sp. as indicators. Protein concentration was used as an indicator of concentration of the formula. Out of 94, 63 (67%) of samples obtained at the clinic and 13/16 (81%) of available home samples were contaminated with faecal bacteria, compared to 8/21 (38%) of those prepared under observation. Out of 94, 58 (62%) of the clinic samples containing E. coli and 23/94 (24%) of those containing Enterococcus sp. were contaminated with more than the US government recommended limit of 10 CFU/ml. Out of 94, 26 (28%) of samples obtained at the clinic, 8/17 (47%) of home samples and 3/21 (14%) of those prepared under observation were over-diluted, compared to standards. Many mothers did not follow recommended practices in preparing and feeding the bottles.

Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa.

BACKGROUND: Breast problems, including mastitis, can interfere with the duration and exclusivity of breast-feeding. However, there are no large prospective studies documenting the prevalence, duration, and timing of such problems in breast-feeding women, particularly those who are infected with human immunodeficiency virus (HIV). METHODS: Women enrolled prenatally underwent a breast-feeding counseling intervention until 6 months after delivery. Breast health problems were documented per breast for 180 days after delivery, with 14-day recall histories. RESULTS: Breast health problems were rare, and there were no significant differences between HIV-infected and HIV-uninfected women for any of the following conditions: engorgement, 39 HIV-infected women (3.5%) versus 33 HIV-uninfected women (2.7%; P=.30); breast thrush, 17 (1.5%) versus 12 (1.0%; P=.25); bleeding nipple, 6 (0.5%) versus 4 (0.3%; P=.45); and mastitis/abscess, 11 (1.0%) versus 6 (0.5%; P=.17). Most problems occurred during the first month after birth, with few additional mothers experiencing problems after this point: at 1 and 6 months, 13% and 17% of all mothers, respectively, had experienced a minor or major breast health problem, including sore nipples. Women who had not exclusively breast-fed their infants were more likely to experience any of the breast health problems than were women who had exclusively breast-fed their infants (time-dependent variable; adjusted odds ratio, 1.46; 95% confidence interval, 1.13-1.87; P=.003). HIV-infected women who experienced any serious breast health problem (i.e., bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess) were 3.55 times (95% confidence interval, 0.86-14.78 times; P=.08) more likely to transmit HIV postnatally to their infant. CONCLUSIONS: With encouragement to exclusively breast-feed, women experienced few breast health problems. When those problems did occur, HIV-infected women with bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess were more likely to transmit HIV to their infants.

Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice.

OBJECTIVE: To examine infant feeding intentions of HIV-infected and uninfected women and the appropriateness of their choices according to their home resources; and to determine their adherence to their intentions in the first postnatal week. METHODS: Feeding intentions of pregnant women were compared against four resources that facilitate replacement feeding: clean water, adequate fuel, access to a refrigerator and regular maternal income. First-week feeding practices were documented. FINDINGS: The antenatal feeding intentions of 1253 HIV-infected women were: exclusive breastfeeding 73%; replacement feeding 9%; undecided 18%. Three percent had access to all four resources, of whom 23% chose replacement feeding. Of those choosing replacement feeding, 8% had access to all four resources. A clean water supply and regular maternal income were independently associated with intention to replacement feed (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI) 1.2-3.2; AOR 2.1, 95% CI: 1.2-3.5, respectively). Significantly more HIV-infected women intending to exclusively breastfeed, rather than replacement feed, adhered to their intention in week one (exclusive breastfeeding 78%; replacement feeding 42%; P<0.001). Of 1238 HIV-uninfected women, 82% intended to exclusively breastfeed; 2% to replacement feed; and 16% were undecided. Seventy-five percent who intended to exclusively breastfeed adhered to this intention postnatally, and only 11 infants (<1%) received no breast milk. The number of antenatal home visits significantly influenced adherence to feeding intention. CONCLUSION: Most HIV-infected women did not have the resources for safe replacement feeding, instead choosing appropriately to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counselling and support, spillover of suboptimal feeding practices to HIV-negative women is minimal.

The effect of nutritional support on weight gain of HIV-infected children with prolonged diarrhoea.

AIM: To examine the effect on growth and immunity of enhanced calorie and protein provision to HIV-infected children presenting with prolonged diarrhoea. METHODS: A total of 169 HIV-infected children aged 6-36 months with diarrhoea for 7 days or more were randomly assigned to either standard nutrition support for children with prolonged diarrhoea or an enhanced diet started during hospitalisation and continued after discharge. The change in weight between enrolment and 8, 14 and 26 weeks and changes in plasma HIV-RNA and CD4 cell count at 8 and 26 weeks were estimated. RESULTS: Children receiving enhanced nutrition achieved significantly more weight gain (p < 0.001) between enrolment and 8 weeks than children on the standard diet (median increase in weight-for-age standard deviation score +1.02 vs. +0.01). After 8 weeks median weight velocity was normal and similar in both groups. The change in median CD4 count was similar in both groups. The 26-week mortality rate was high in both groups (standard support: 22%, enhanced support: 29%). CONCLUSIONS: Nutrition support of children with advanced HIV infection and prolonged diarrhoea resulted in significant and sustained weight gain, but did not improve CD4 counts or survival. These results support integrated nutrition interventions for HIV-infected children.

Are WHO/UNAIDS/UNICEF-recommended replacement milks for infants of HIV-infected mothers appropriate in the South African context?

OBJECTIVE: Little is known about the nutritional adequacy and feasibility of breastmilk replacement options recommended by WHO/UNAIDS/UNICEF. The study aim was to explore suitability of the 2001 feeding recommendations for infants of HIV-infected mothers for a rural region in KwaZulu Natal, South Africa specifically with respect to adequacy of micronutrients and essential fatty acids, cost, and preparation times of replacement milks. METHODS: Nutritional adequacy, cost, and preparation time of home-prepared replacement milks containing powdered full cream milk (PM) and fresh full cream milk (FM) and different micronutrient supplements (2 g UNICEF micronutrient sachet, government supplement routinely available in district public health clinics, and best available liquid paediatric supplement found in local pharmacies) were compared. Costs of locally available ingredients for replacement milk were used to calculate monthly costs for infants aged one, three, and six months. Total monthly costs of ingredients of commercial and home-prepared replacement milks were compared with each other and the average monthly income of domestic or shop workers. Time needed to prepare one feed of replacement milk was simulated. FINDINGS: When mixed with water, sugar, and each micronutrient supplement, PM and FM provided <50% of estimated required amounts for vitamins E and C, folic acid, iodine, and selenium and <75% for zinc and pantothenic acid. PM and FM made with UNICEF micronutrient sachets provided 30% adequate intake for niacin. FM prepared with any micronutrient supplement provided no more than 32% vitamin D. All PMs provided more than adequate amounts of vitamin D. Compared with the commercial formula, PM and FM provided 8-60% of vitamins A, E, and C, folic acid, manganese, zinc, and iodine. Preparations of PM and FM provided 11% minimum recommended linoleic acid and 67% minimum recommended alpha-linolenic acid per 450 ml mixture. It took 21-25 minutes to optimally prepare 120 ml of replacement feed from PM or commercial infant formula and 30-35 minutes for the fresh milk preparation. PM or FM cost approximately 20% of monthly income averaged over the first six months of life; commercial formula cost approximately 32%. CONCLUSION: No home-prepared replacement milks in South Africa meet all estimated micronutrient and essential fatty acid requirements of infants aged <6 months. Commercial infant formula is the only replacement milk that meets all nutritional needs. Revisions of WHO/UNAIDS/UNICEF HIV and infant feeding course replacement milk options are needed. If replacement milks are to provide total nutrition, preparations should include vegetable oils, such as soybean oil, as a source of linoleic and alpha-linolenic acids, and additional vitamins and minerals.

Maternal recall of exclusive breast feeding duration.

BACKGROUND: Both the pattern and duration of breast feeding are important determinants of health outcomes. In vertical HIV transmission research, reliable documentation of early breast feeding practices is important in order to correctly attribute postnatal transmission to feeding pattern. AIMS: To validate methods of collecting data on the duration of exclusive breast feeding (EBF) in an area of South Africa with a high HIV prevalence rate. METHODS: A total of 130 mothers were interviewed weekly, postnatally. At every interview a 48 hour and a seven day recall breast feeding history were taken. A subset of 70 mothers also received two intermediate visits per week during which additional 48 hour, non-overlapping, recall interviews were conducted. Ninety three infants were revisited at 6-9 months of age when mothers' recall of EBF duration from birth was documented. The different methods of recalling EBF status were compared against an a priori "best comparison" in each case. RESULTS: Reported breast feeding practices over the previous 48 hours did not reflect EBF practices since birth (specificity 65-89%; positive predictive value 31-48%). Six month EBF duration recall was equally poor (sensitivity at 2 weeks 79%; specificity 40%). Seven day recall accurately reflected EBF practices compared with thrice weekly recall over the same time period (sensitivity 96%, specificity 94%). CONCLUSIONS: 48 hour EBF status does not accurately reflect feeding practices since birth. Long term recall data on EBF are even more inaccurate. We recommend that data on duration of EBF be collected prospectively at intervals of no longer than one week.

Prevalence, incidence, and mother-to-child transmission of HIV-1 in rural South Africa.

Simple, robust approaches are needed to monitor prevalence, incidence, and mother-to-child transmission of HIV-1 in rural Africa. We have designed a method that uses antibody and viral RNA testing of dried blood spots obtained from mother-infant pairs attending routine immunisation clinics. In our study, prevalence and incidence of HIV-1 was highest in young women in their late teens and early twenties. In children born to infected mothers, prevalence increased from 14% in infants younger than 6 weeks of age to 24% at 3-6 months. The blood-spot approach is an effective method for surveillance of HIV-1 in women and children, and for early identification of incidence of this infection in women of child-bearing age.

Breastfeeding practices in an area of high HIV prevalence in rural South Africa.

UNLABELLED: Exclusive breastfeeding (EBF) from 0 to 6 mo of age is recommended by the World Health Organization as the optimal feeding method for infants, including infants of human immunodeficiency virus (HIV)-infected women from developing countries who choose to breastfeed. EBF may be associated with less risk of postnatal HIV transmission than mixed feeding, but is still uncommonly practised for reasons that are poorly understood. This study aimed to assess EBF rates and the impediments to EBF in a South African rural area of high HIV prevalence where most mothers are unaware of their status. In a longitudinal study, 130 women attending 3 clinics, chosen for their disparate socioeconomic characteristics, were interviewed at weekly postnatal intervals. Follow-up to 16 wk was completed on 119 infants. In an additional cross-sectional survey mothers of 445 infants, aged 0-12 mo, attending immunization clinics were interviewed. In the longitudinal study 46% of infants received non-breast-milk fluids or feeds within 48 h of birth; only 10% were exclusively breastfed for 6 wk and 6% for 16 wk. Supplements, most commonly formula milk, were introduced for perceived milk insufficiency. Feeding choices were mainly self-determined (43% of women), but health staff (22%) and grandmothers (16%) were cited as sources of advice. In the cross-sectional survey caregivers reported that 47% of infants aged 2 wk, 40% aged 6 wk and 33% aged 12 wk had been exclusively breastfed since birth. CONCLUSION: EBF is uncommon in this area in spite of a baby-friendly hospital initiative in the district. Strategies to promote exclusive breastfeeding in developing countries where HIV and infant feeding policies are being formulated must strongly address local perceptions on the need for supplements and sources of feeding advice.

Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women.

Exclusive breast feeding has been associated with a lower rate of mother-to-child HIV transmission than breast feeding plus other foods. To obtain further information on biologic outcomes of different feeding modes, we examined 272 infants of HIV-infected South African women at ages 1, 6, and 14 weeks. At each visit information about infant diet and morbidity was collected and infants underwent a lactulose/mannitol dual sugar intestinal permeability test. In a subset of infants, urinary neopterin excretion was measured as an indicator of immune system activation. Infants who had themselves become HIV-infected by 14 weeks had higher ( p <.01) intestinal permeability at 6 and 14 weeks and slightly (.05 < p <.1) higher neopterin excretion at all times than uninfected infants. At 1 week infants given no breast milk had higher ( p <.05) intestinal permeability than infants given breast milk exclusively or with other foods. Intestinal permeability in infants fed breast milk plus other foods was never increased relative to that of exclusively breastfed infants. Feeding mode had no effect on neopterin excretion. Thus, infant HIV infection induces changes in gut permeability and possibly immune system activation before clinical symptoms become apparent. The effects of feeding mode on infant intestinal permeability or urinary neopterin excretion do not explain a possible protective effect of exclusive breast feeding on mother-to-child transmission of HIV.

The effect of antenatal vitamin A and beta-carotene supplementation on gut integrity of infants of HIV-infected South African women.

BACKGROUND: Vitamin A is important for protection against diarrhea, and supplements may benefit gut function of infants of HIV-infected mothers. METHODS: We studied 238 infants of HIV-infected South African women participating in a randomized, double-blind, placebo-controlled trial of vitamin A during pregnancy (1.5 mg retinyl palmitate and 30 mg beta-carotene daily) plus 60 mg retinyl palmitate at delivery. The placebo group received identical placebo capsules at the same times. When infants were 1, 6, and 14 weeks of age, lactulose/mannitol dual sugar intestinal permeability tests were performed. RESULTS: Maternal vitamin A supplementation did not significantly affect infant gut permeability in the group as a whole at any time. By multiple regression analysis, HIV infection of the infant by 14 weeks was significantly associated with increased gut permeability at both 6 and 14 weeks. After controlling for birth weight, gestational age, current weight, feeding mode and recent morbidity, there was a trend toward an interaction between vitamin A supplementation and HIV infection (P = 0.086) at 14 weeks. Vitamin A made no difference to gut permeability of uninfected infants (lactulose/mannitol ratio for vitamin A group: 0.11, 95% confidence interval [CI] 0.08, 0.15, n = 73 and for placebo group: 0.09, 95% CI 0.06, 0.12, n = 76), but largely prevented the increase in the ratio of HIV-infected infants (vitamin A group: 0.17, 95% CI 0.13, 0.23, n = 23; placebo group: 0.50, 95% CI 0.37, 0.68, n = 20). The effects on the lactulose/mannitol ratio were related to changes in lactulose, not mannitol, excretion. Vitamin A supplementation was associated with significantly lower lactulose excretion at 1 and 14 weeks, suggesting the major effect of vitamin A was on maintaining the integrity of gut tight junctions. CONCLUSIONS: Vitamin A supplementation of HIV-infected pregnant women may prevent the deterioration in gut integrity in the subgroup of their infants who themselves become infected. Improving vitamin A status of HIV-infected infants may decrease their gastrointestinal morbidity.

Vitamin A supplementation of South African children with severe diarrhea: optimum timing for improving biochemical and clinical recovery and subsequent vitamin A status.

BACKGROUND: Vitamin A has well-recognized benefits for prevention of diarrhea, but the impact of therapeutic doses given during diarrhea on biochemical and clinical outcomes is less clear. We investigated these potential therapeutic benefits within a study of the optimum time for vitamin A supplementation to promote vitamin A status. METHODS: Young children with severe diarrhea were randomized to receive 60 mg of retinol as retinyl palmitate during acute diarrhea or once symptoms had resolved, usually after 5 to 8 days. Either during acute diarrhea or after its resolution, children not receiving vitamin A were given identical placebo. On Days 0 and 3 we measured urinary neopterin, plasma retinol and acute phase proteins and intestinal permeability by the lactulose/mannitol test. Eight weeks after discharge children returned to hospital for a modified dose response test of vitamin A stores. RESULTS: Most children presented with watery diarrhea and grossly abnormal intestinal permeability and immune activation markers. At 8 weeks plasma retinol concentrations of children receiving vitamin A during acute diarrhea, compared with those receiving it in early convalescence [0.67 (95% confidence interval, 0.58 to 0.76) micromol/l vs. 0.68 (95% confidence interval, 0.59 to 0.79) micromol/l], and the proportion of children with deficient vitamin A stores (7 of 34 vs. 8 of 34) did not differ. Clinical features, lactulose/mannitol tests and urinary neopterin concentrations on Day 3 also did not differ significantly when vitamin A was given early or late. CONCLUSIONS: Even when it was given during severe diarrhea, a large dose of vitamin A improved vitamin A stores in a population in whom vitamin A deficiency is a public health problem. Vitamin A did not significantly improve early clinical or biochemical recovery from severe diarrhea.

Post-dysenteric hemolytic uremic syndrome in children during an epidemic of Shigella dysentery in Kwazulu/Natal.

We report 81 of 107 cases of hemolytic uremic syndrome (HUS), admitted between July 1994 and February 1996, following an outbreak of Shigella dysenteriae type 1 dysentery in Kwazulu/Natal. All patients, excluding 1, were black with a mean age of 38 months (range 1-121); 50 (61.7%) were males. The mean duration of dysentery was 11.3 days (range 1-41) and HUS 15 days (range 1-91). Most patients had acute oliguric renal failure (90.1%), 42 (51.6%) required peritoneal dialysis. Complications included encephalopathy 30 (37.0%), convulsions 12 (14.8%) and hemiplegia 2 (2.3%), gastrointestinal perforation 8 (9.9%), protein losing enteropathy 26 (32.1%), toxic megacolon 4 (4.9%), rectal prolapse 5 (6.2%), hepatitis 11 (13.6%), myocarditis 5 (6.2%), congestive cardiac failure 3 (3.7%), cardiomyopathy 3 (3.7%), infective endocarditis 1 (1.2%), septicemia 15 (18.5%), disseminated intravascular coagulation 17 (21%). Leukemoid reactions were found in 74 (91.3%) patients, hyponatremia in 56 (69.1%), and hypoalbuminemia in 67 (82.7%). Stool culture for Shigella dysenteriae type I was positive in only 7 (8.6%) patients; Shiga toxin assays were not performed. Outcome was as follows: recovery 32 (39.5%), impaired renal function 8 (9.9%), chronic renal failure 26 (32.1%), end-stage renal disease 1 (1.2%), and death 14 (17.3%) patients.

Epidemic Shigella dysenteriae type 1 in Natal.

Since its first isolation in South Africa in 1994, Shigella dysenteriae type 1 has now spread to cause an epidemic outbreak in Natal Kwazulu, resulting in a steep rise in admissions for dysentery and the haemolytic uraemic syndrome in children. We report on the epidemic as it has evolved so far. A large outbreak is to be expected in South Africa in view of large scale poverty, lack of housing, and adequate water and sanitation, unless urgent public health measures are taken.