Evaluating Nurses' Implementation of an Infant-Feeding Counseling Protocol for HIV-Infected Mothers: The Ban Study in Lilongwe, Malawi

The Journal of Nutrition

et al. 2012

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The Breastfeeding, Antiretrovirals, and Nutrition Study evaluated the effect of daily consumption of lipid-based nutrient supplements (LNS) by 2121 lactating, HIV-infected mothers on the growth of their exclusively breast-fed, HIV-uninfected infants from 0 to 24 wk. The study had a 2 × 3 factorial design. Malawian mothers with CD4(+) ≥250 cells/mm(3), hemoglobin ≥70 g/L, and BMI ≥17 kg/m(2) were randomized within 36 h of delivery to receive either no LNS or 140 g/d of LNS to meet lactation energy and protein needs, and mother-infant pairs were assigned to maternal antiretroviral drugs (ARV), infant ARV, or no ARV. Sex-stratified, longitudinal, random effects models were used to estimate the effect of the 6 study arms on infant weight, length, and BMI. Logistic regression models were used to calculate the odds of growth faltering [decline in weight-for-age Z-score (WAZ) or length-for-age Z-score (LAZ) >0.67] using the control arm as the reference. Although some differences between study arms emerged with increasing infant age in boys, there were no consistent effects of the maternal supplement across the 3 growth outcomes in longitudinal models. At the ages where differences were observed, the effects on weight and BMI were quite small (≤200 g and ≤0.4 kg/m(2)) and unlikely to be of clinical importance. Overall, 21 and 34% of infants faltered in WAZ and LAZ, respectively. Maternal supplementation did not reduce the odds of infant weight or length faltering from 0 to 24 wk in any arm. These results indicate that blanket supplementation of HIV-infected lactating women may have little impact on infant growth.

Section: Discussionmentioning

confidence: 89%

Section: Study Interventionsmentioning

confidence: 99%

Use of Lipid-Based Nutrient Supplements by HIV-Infected Malawian Women during Lactation Has No Effect on Infant Growth from 0 to 24 Weeks

Flax

The Journal of Nutrition

et al. 2012

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“…In addition, prevalence of any diarrhea in BAN infants was lower for similar time periods than among Zambian HIV-exposed infants who were weaned at 4 mo (43% at 7-9 mo and 44% at 10-12 mo) as well as those who were still breastfed (38% at 7-9 mo and 39% at 10-12 mo) (5). This could be attributable in part to the provision of LNS (which is resistant to bacteriologic growth) as a breastmilk replacement or to the counseling on replacement feeding practices provided by the study (19,42).…”

Section: Discussionmentioning

confidence: 94%

“…The randomized interventions were provided from 0 to 28 wk. Mothers in the BAN Study were counseled to exclusively breastfeed for 24 wk then wean their infants within 4 wk (19). To address the possibility of inadequate feeding following weaning (20), all infants were provided with lipid-based nutrient supplements (LNS) from 24 to 48 wk of age.…”

Section: Introductionmentioning

confidence: 99%

Lipid-Based Nutrient Supplements Are Feasible As a Breastmilk Replacement for HIV-Exposed Infants from 24 to 48 Weeks of Age

Flax

The Journal of Nutrition

et al. 2013

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The Breastfeeding, Antiretrovirals, and Nutrition (BAN) Study randomized HIV-infected mothers and their infants to receive either maternal lipid-based nutrient supplements (LNS) during lactation or no LNS and then to 1 of 3 antiretroviral drug (ARV) arms (maternal, infant, or no drugs). Assigned interventions were provided from 0 to 28 wk and all infants (n = 1619) were given LNS during (24-28 wk) and following (28-48 wk) weaning. This paper assesses the feasibility of infant LNS as a breastmilk replacement and uses longitudinal random effects models to examine associations of interventions, morbidity, and season with weight-for-age (WAZ), length-for-age (LAZ), and BMI-for-age (BMIZ) Z-scores from 24 to 48 wk. Infant LNS adherence was high (94.1% ate it daily). From 24 to 48 wk, mean WAZ (-0.42 to -0.76 SD; P < 0.001) and LAZ (-0.93 to -1.56 SD; P < 0.001) steadily declined, whereas BMIZ remained >0 throughout. A higher LAZ was associated with assignment to the maternal LNS arm (β=0.19; P < 0.05). Lower WAZ and BMIZ were associated with seasonal food insecurity (β=-0.08 and -0.09, respectively; both P < 0.001), fever (β=-0.07 and -0.13; both P < 0.001), diarrhea (β=-0.19 and -0.23; both P < 0.001), and assignment to the infant ARV arm (β=-0.17 and -0.17; both P < 0.05). The magnitude of the season and morbidity effects was small and BAN infants had higher weights and lengths than their counterparts in the general population. High LNS adherence and the modest impact of morbidity on growth indicate that LNS is a feasible breastmilk replacement for HIV-exposed infants weaned early, but controlled trials are needed to quantify the effects of LNS on growth in this population.

“…This analysis includes data from 0-24 weeks, when mothers were provided with intensive counseling to exclusively breastfeed. 26,27 Maternal Hb was measured at prenatal screening and maternal and infant Hb (g/L) was measured at birth, 2, 6, 12, 18 and 24 weeks postpartum from venous blood samples with a Beckman Coulter AcT or AcT 5-part Differential Analyzer (Beckman Coulter, Fullerton, CA). Infant HIV status was tested with Amplicor 1.5 DNA polymerase-chain reaction.…”

Section: Methodsmentioning

confidence: 99%

Antiretroviral Treatment Is Associated With Iron Deficiency in HIV-Infected Malawian Women That Is Mitigated With Supplementation, but Is Not Associated With Infant Iron Deficiency During 24 Weeks of Exclusive Breastfeeding

Widen

JAIDS Journal of Acquired Immune Deficiency Syndromes

et al. 2015

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Objective In resource-limited settings without safe alternatives to breastfeeding, the WHO recommends exclusive breastfeeding and antiretroviral (ARV) prophylaxis. Given the high prevalence of anemia among HIV-infected women, mothers and their infants (via fetal iron accretion) may be at risk of iron deficiency. We assessed the effects of maternal micronutrient-fortified lipid-based nutrient supplements (LNS) and maternal ARV treatment or infant ARV prophylaxis on maternal and infant iron status during exclusive breastfeeding from birth to 24 weeks. Methods The Breastfeeding, Antiretrovirals, and Nutrition Study was a randomized controlled trial conducted in Lilongwe, Malawi from 2004-2010. HIV-infected mothers (CD4>200 cells/ul) and their infants were randomly assigned to 28-week interventions: maternal-LNS/maternal-ARV (n=424), maternal-LNS/infant-ARV (n=426), maternal-LNS (n=334), maternal-ARV (n=425), infant-ARV (n=426), or control (n=334). Longitudinal models tested intervention effects on hemoglobin (Hb). In a subsample (n=537) with multiple iron indicators, intervention effects on Hb, transferrin receptors (TfR) and ferritin were tested with linear and Poisson regression. Results In longitudinal models, LNS effects on maternal and infant Hb were minimal. In subsample mothers, maternal ARVs were associated with tissue iron depletion (TfR>8.3 mg/L) (Risk ratio (RR): 3.1, p<0.01), but not in ARV-treated mothers receiving LNS (p=0.17). LNS without ARVs, was not associated with iron deficiency or anemia (p>0.1). In subsample infants, interventions were not associated with impaired iron status (all p-values>0.1). Conclusions Maternal ARV treatment with protease inhibitors is associated with maternal tissue iron depletion; but LNS mitigates adverse effects. ARVs do not appear to influence infant iron status; however, extended use needs to be evaluated.