Malawi PMTCT Trainer Manual
Module 4 Infant Feeding in the Context of HIV Infection
/ Total Time: 280 minutesAfter completing the module, the participant will be able to:
· Define key infant feeding terms
· Describe the key infant feeding recommendations based on National PMTCT Guidelines and Infant and Young Child Nutrition Policy and Guidelines, 2005-2010.
· Give an overview of the National Code of Marketing of Infant and Young Child Foods
· Give an overview of the Baby Friendly Hospital Initiative
· Discuss the main infant feeding options in Malawi and their advantages and disadvantages.
· Demonstrate step-by-step safe preparation of commercial formula and home-modified animal milk.
· Demonstrate steps in infant feeding counselling for HIV-positive mothers.
Have the following additional materials available, whenever possible:
· Malawi Ministry of Health’s Infant and Young Child Nutrition Policy and Guidelines, 2005-2010
· National PMTCT guidelines
· Doll to model good breastfeeding techniques
· Two sets of utensils and supplies: one to prepare commercial infant formula and the other to prepare home-modified animal milk:
· Two types of milks that are commonly used for replacement feeding (e.g., commercial infant formula, powdered full cream milk, cow’s milk)
· Utensils and tools to measure: if by volume, then measuring cups or containers that have been marked in millimetre; if by weight, then a scale or coins, rulers, matchbox.
· Easily available see-through small containers such as jars or glasses
· Feeding cups
· Permanent marker
· Spoons
· Water
· Sugar
· Small cloth to work on when weighing sugar (e.g., clean handkerchief)
· Micronutrient supplement
· About 2 litres of drinking water plus water for washing up
· Source of energy (e.g., electricity, firewood, charcoal)
Note: The demonstration will only simulate the preparation of replacement feeds. There will be no actual boiling of water.
Unit 1 Overview of Infant Feeding Recommendations
Activity/Method / TimeInteractive lecture / 50 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 60 minutes
Unit 2 Infant Feeding Options
Activity/Method / TimeInteractive lecture / 60 minutes
Overview of content in Appendices 4-C, 4-D, 4-E, 4-F, 4-G and 4-H, Interactive lecture / 30 minutes
Exercise 4.1 Demonstration of preparation of commercial infant formula and home-modified animal milk / 60 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 160 minutes
Unit 3 Supportive Counselling for Safer Infant Feeding Choices
Activity/Method / Time /Interactive lecture / 20 minutes
Exercise 4.2 Infant feeding counselling and support role play / 30 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 60 minutes
Note on this module
This module is designed to provide the HCW with the basic knowledge and introductory skills for infant feeding counselling in PMTCT settings. Additional infant feeding counselling training is strongly encouraged, and should be considered whenever possible.
/ Trainer Instructions
Slides 1-3
Begin by reviewing the module objectives listed above.
UNIT 1 Overview of Infant Feeding Recommendations
The trainer should become familiar with the National Code of Marketing of Infant and Young Child Foods and the Baby Friendly Hospital Initiative (Appendix 4-A). The trainer should also be familiar with the Malawi Ministry of Health’s Infant and Young Child Nutrition Policy and Guidelines, 2005-2010 as well as National PMTCT Guidelines
/ Total Unit Time: 60 minutes
/ Trainer Instructions
Slides 4-5
Introduce the unit and review objectives.
After completing the unit, the participant will be able to:
· Define key infant feeding terms
· Describe the key infant feeding recommendations based on National PMTCT Guidelines and Infant and Young Child Nutrition Policy and Guidelines, 2005-2010.
· Give an overview of the National Code of Marketing of Infant and Young Child Foods
· Give an overview of the Baby Friendly Hospital Initiative
/ Trainer InstructionsSlide 6
Present the following basic facts about malnutrition, infant feeding and child survival.
Discussion questions· What are the main causes of illness in the children you care for in your work?
· What proportion of illnesses that you see are caused by poor infant nutrition?
· What are some causes of poor nutrition? (Answers could include “feeding the infant food or liquids that are not nutritious,” “feeding the infant foods or liquids made with unclean water.”)
/ Make These Points
· Poor nutrition is a major cause of illness in children.
· Mothers who are HIV-infected need counselling and support for safer feeding practices.
· For infant and young child feeding, it is the strategy of WHO and UNICEF to create a global environment that empowers women to breastfeed exclusively for the first six months of a child’s life. Refer participants to Appendix 4-A for a summary on the Global Strategy for Infant and Young Child Feeding.
Basic facts on malnutrition, infant feeding and child survival
· Malnutrition is the underlying cause of death in about 60% of children younger than 5 years old worldwide and in about 50% of children that age in Africa.
· Being underweight was associated with 3.7 million deaths worldwide in the year 2000, and most of the deaths occurred in children younger than 5 years old.
· In Malawi, 48% of children under the age of five years are stunted, 22% are underweight, and 5% present with wasting.
· In Malawi, malnutrition has been exacerbated by the HIV epidemic and singled out as one of the major contributing factors to the high infant, young child and maternal mortality rates in the country.
· The Malawi Demographic and Health Survey (MDHS 2004) estimated that the infant mortality rate is 76 per 1,000 live births. The young child (under the age of 5 years) mortality rate is 133 per 1000 live births/year.
· Poor feeding practices, such as early mixed feeding, inadequate complementary feeding, or poor hygiene contributing to diarrhoea, are a major cause of low weight and high morbidity and mortality among children.
· Counselling and support for infant feeding can improve feeding practices and, in turn, prevent malnutrition and reduce the risk of illness and death in children.
· For mothers who are HIV-infected, counselling and support may lead to improved infant feeding practices that also may help prevent MTCT.
International agencies such as WHO and UNICEF have therefore developed strategies to promote, protect and support appropriate infant and young child feeding. Refer to Appendix 4-A for global recommendations on infant and young child feeding.
/ Trainer InstructionsSlides 7-8
Provide an overview of infant feeding in the context of HIV in Malawi.
Explain the significance of infant feeding to PMTCT: explain that HIV can be transmitted through breastfeeding, even if the mother and/or baby took (or is taking) ARV prophylaxis or therapy. However, scientific information is still emerging on decreased viral load in breastmilk in women on ARV therapy.
Overview of infant feeding in the Context of HIV
Antiretroviral (ARV) therapy and prophylaxis have substantially reduced mother-to-child transmission of HIV (MTCT). ARV prophylaxis, however, does not provide long-term protection for the infant who is breastfeeding.
Without intervention, 10% to 20% of infants breastfed by mothers who are HIV-infected may acquire HIV infection during breastfeeding. Infant feeding practices that carefully follow national or UN guidelines can reduce the likelihood of MTCT during breastfeeding and also reduce the risk of infant death from diarrhoea and other childhood infections.
Breastmilk is the ideal nourishment for infants for the first six months of life, as it contains all the nutrients, antibodies, hormones and antioxidants an infant needs to thrive. It protects babies from diarrhoea and acute respiratory infections, and stimulates their immune system response to other diseases and to vaccinations.
Risk factors for transmission of HIV from mother-to-child during breastfeeding
Maternal risk factors / Infant risk factors· High maternal viral load (new infection or advanced AIDS), which will affect amount of virus in breastmilk
· Breast infections (mastitis, abscess, bleeding nipples)
· Characteristics of the virus / · Duration of breastfeeding
· Non-exclusive breastfeeding (mixed feeding)
· Infant age (transmission is highest in the first months of life)
· Lesions in the mouth, intestines
· Premature birth
· Infant immune response
Infant feeding in the context of HIV in Malawi
Even though breastfeeding is practised by almost all mothers (97%) in Malawi, exclusive breastfeeding (EBF) for the first 6 months of life is practised by only 53% of mothers. Although most mothers breastfeed for almost 2 years, infants are not given timely, appropriate or adequate nutrient-rich and energy-dense foods to complement breast milk from age 6 months to 24 months and older. Malnutrition levels are therefore still high: 48% of children under the age of five years are stunted, 22% are underweight, and 5% present with wasting. This is mainly due to poor feeding and caring practices.
To address the situation, the Malawi Ministry of Health has issued the following guidance:
· EBF is recommended for all infants during the first 6 month of life unless medically contraindicated.
· Children of HIV-negative mothers should continue breastfeeding from 6-24 months or beyond along with appropriate complementary foods.
· For infants of HIV-infected mothers, exclusive breastfeeding is recommended during the first months of life. Early cessation at 6 months followed with other forms of milk or food is recommended. Mothers are counselled on other feeding options and supported in making informed choices.
· Where use of breastmilk substitutes (BMS) is recommended, service providers and mothers should ensure that the marketing and use of BMS is in compliance with the National Code of Marketing Infants and Young Child Foods.
· All children aged 6-59 months receive vitamin A supplementation according to EPI schedule.
· Growth monitoring and health promotional activities are provided at all levels as a preventive strategy aimed at taking specific action to avert poor physical and psychosocial development of the child.
· The multimix principle based on the six food groups is promoted by all stakeholders for infant and child diets (see Appendix 4-K for additional information).
/ Trainer InstructionsSlides 9-13
Before proceeding with other infant feeding discussions, tell participants that the group will now define key infant feeding terms. Start by showing the slides with the key terms.
Discussion questions· Which of these key infant feeding terms are you familiar with?
· Which terms are new?
· Who would like to define the first term? Who would like to amend the definition? Do we have a consensus? (Proceed similarly until you have completed defining all the terms.)
· Are you clear on the distinctions between “replacement feeding” and “commercial infant formula” and “home-modified animal milk”? (Ensure that participants are clear on the distinctions between the terms.)
Key infant feeding terms
· Exclusive breastfeeding (EBF): all the infant’s fluid energy and nutrients are provided by breastmilk.
· The baby should not be given any drinks (not even water) or foods other than breastmilk, except for drops or syrups containing vitamins, mineral supplements, or medicine when indicated.
· The baby may receive expressed breastmilk
· The baby should not be given pacifiers, dummies, or artificial teats.
· There should be no limits placed on the number of breastfeeds.
· There should be no limits placed on length of a breastfeed or on suckling time.
· Newborn babies should breastfeed eight to twelve times in 24 hours, including night feeds.
· Mixed feeding: when the infant who is breastfed is also given other liquids, such as water, tea, formula, or cow’s milk, or foods such as porridge or rice during the first six months of life.
· Wet-nursing: having another woman breastfeed a baby, in this case a woman who has tested HIV-negative.
· Expressing and heat-treating breastmilk: removing the milk from the breasts manually or with a pump, and then heating it to kill HIV.
· Replacement feeding: the infant who is receiving no breastmilk is given a diet that provides all the nutrients the infant needs until the age at which he/she can be fully fed on family foods. During the first 6 months of life, replacement feeding should be with a suitable breastmilk substitute such as commercial infant formula or home-modified animal milk. After the child is 6 months old, other foods should be offered to complement the breastmilk substitute.
· Commercial infant formula: a breastmilk substitute consisting of specially-formulated powdered milk. Commercial infant formula is made specifically for infants and sold in shops or provided by other means to HIV-infected mothers who choose not to breastfeed. They can feed their infant or child commercial infant formula to prevent HIV transmission.
· Home-modified animal milk: made from fresh liquid (or full cream powder) animal milk and modified using a standard or specific recipe.
· Complementary feeding: feeding babies who are older than 6 months of age foods and liquids in addition to breastmilk or a breastmilk substitute.
/ Trainer InstructionsSlides 14-16
Discuss the national recommendations for mothers who are HIV-negative and mothers with unknown HIV status. Review the definition of EBF. Review the advantages of EBF. Clarify any misunderstanding about breastfeeding and HIV transmission.
Review the infant feeding recommendations for mothers who are HIV-infected. Introduce “acceptable, feasible, affordable, sustainable and safe” (AFASS) as the criteria for assessing the appropriateness of replacement feeding. Note that the group will return to these concepts later in this module.