Effect of vitamin supplementation on breast milk concentrations of retinol, carotenoids and tocopherols in HIV-infected Tanzanian women

Abstract

Background/Objective: The effect of daily prenatal and postnatal vitamin supplementation on concentrations of breast milk nutrients is not well characterized in HIV-infected women. We examined the impact of vitamin supplementation during pregnancy and lactation on breast milk concentrations of retinol, carotenoids and tocopherols during the first year postpartum among 626 HIV-infected Tanzanian women. Subjects/Methods: We conducted a randomized, double-blind, placebo-controlled trial. Women were assigned to one of four daily oral supplements: vitamin A þ b-carotene (VA þ BC); multivitamins (MV; B, C and E); MV þ VA þ BC or placebo. Concentrations of breast milk nutrients were determined by high-performance liquid chromatography at birth and every 3 months thereafter. Results: Supplementation with VA þ BC increased concentrations of retinol, b-carotene and a-carotene at delivery by 4799, 1791 and 84 nmol l À1 , respectively, compared to no VA þ BC (all Po0.0001). MV supplementation did not increase concentrations of a-tocopherol or d-tocopherol at delivery but significantly decreased concentrations of breast milk g-tocopherol and retinol. Although concentrations of all nutrients decreased significantly by 3 months postpartum, retinol, a-carotene and b-carotene concentrations were significantly higher among those receiving VA þ BC at 3, 6 and 12 months compared to no VA þ BC. a-Tocopherol was significantly higher, while g-tocopherol concentrations were significantly lower, among women receiving MV compared to no MV at 3, 6 and 12 months postpartum. Conclusions: Sustained supplementation of HIV-infected breastfeeding mothers with MV could be a safe and effective intervention to improve vitamin E concentrations in breast milk. VA þ BC supplementation increases concentrations of breast milk retinol but it is not recommended in HIV-infected mothers due to the elevated risk of vertical transmission.

Micronutrients and HIV Infection

“…Another report from this trial demonstrated that neither the multivitamins nor vitamin A affected risk of vertical transmission of HIV-1 in utero, during the intrapartum period or during the early breastfeeding periods [158]. However, this study demonstrated that vitamin A supplementation increased the risk of MTCT, pre-and perinatally [159] and through breastfeeding [131,160], if the supplementation was carried out throughout the breastfeeding period (RR = 1.38; 95% CI: 1.09-1.76; p = 0.009). Conversely, supplementation with the B vitamins and vitamins C and E reduced transmission through breastfeeding (RR: 0.37; 95% CI: 0.16-0.85; p = 0.02) in women with advanced HIV disease at baseline compared with those with high CD4 + T-cell counts [131].…”

Review of randomized controlled trials of nutritional supplementation in people living with HIV

“…70 The three supplementation arms, including those with vitamin A, decreased the burden of malaria in this cohort. 61 Other reports from this trial, however, also described adverse effects, such as increased vertical transmission and increased viral load in breast milk with vitamin A supplementation, without reduction in mortality, 81,[83][84][85] and risk of developing subclinical mastitis with multivitamins. 84 In contrast, Kumwenda et al 98 randomized a cohort of 697 pregnant women in Malawi to receive 3 mg daily of retinol or placebo, in addition to the standard iron and folate supplementation during pregnancy, and concluded that supplementation during pregnancy and postpartum had beneficial effects on newborns' birth weight and prevention of anemia, without changing the rate of mother-to-child transmission.…”

“…81 Multivitamins alone or with vitamin A improved maternal weight gain during the third trimester of pregnancy. 80 Multivitamins during pregnancy and breastfeeding reduced adverse pregnancy and child outcomes, 72 including improving newborns' ponderal weight 71 and vitamin E status, 83 protecting infants against motor developmental delays, 64 reducing maternal wasting, 65 hypertension, 69 symptoms of depression, improving women's quality of life, 63 delaying HIV disease progression during pregnancy, 25 and improving hematological outcomes in both mothers and infants. Supplementation with vitamin A during pregnancy improved the vitamin A status of infants.…”

Effect of vitamin supplements on HIV shedding in breast milk

“…Because vitamin A and b-carotene were administered together in this trial, it is not possible to ascertain the individual effect of each nutrient following an intent-to-treat analytic approach. Nevertheless, in an effort to identify the separate effects of each nutrient, we evaluated the associations between viral or proviral HIV concentrations and retinol or b-carotene concentrations in breast milk using an observational, cross-sectional design in which we took advantage of the treatment's large effect on the variability of breastmilk nutrient concentrations (11). A key aspect of these analyses was the simultaneous adjustment for retinol and b-carotene concentrations in the models to overcome confounding of the effect of one nutrient by the other's given that they shared the same major source (treatment assignment) in half of the population.…”

“…Retinol and b-carotene concentrations were quantified in the whole-milk aliquot with the use of HPLC (Restek Corp, Bellefonte, PA), as previously described in detail (11). The minimum detection limits were 3.12 and 1.65 nmol/L for retinol and b-carotene, respectively.…”