Optimal infant- and young child–feeding practices are crucial for nutritional status, growth, development, health and, ultimately, survival. Human breast milk is optimal nutrition for all infants. Complementary food introduced at the correct age is part of optimal feeding practices. In South Africa, widespread access to antiretrovirals and a programme to prevent mother-to-child transmission of HIV have reduced HIV infection in infants and increased the number of HIV-exposed uninfected (HEU) infants. However, little is known about the feeding practices and nutritional status of HEU and HIV-unexposed (HU) infants.
To assess the feeding practices and nutritional status of HIV-exposed and HIV-unexposed (HU) infants in the Western Cape.
Prospective substudy on feeding practices nested in a pilot study investigating the innate immune abnormalities in HEU infants compared to HU infants. The main study commenced at week 2 of life with the nutrition component added from 6 months. Information on children’s dietary intake was obtained at each visit from the caregiver, mainly the mother. Head circumference, weight and length were recorded at each visit. Data were obtained from 6-, 12- and 18-month visits. World Health Organization feeding practice indicators and nutrition indicators were utilised.
Tygerberg Academic Hospital, Western Cape. Mothers were recruited from the postnatal wards.
Forty-seven mother–infant pairs, 25 HEU and 22 HU infants, participated in this nutritional substudy. Eight (17%) infants, one HU and seven HEU, were lost to follow-up over the next 12 months. The HEU children were mainly Xhosa (76%) and HU were mainly mixed race (77%).
The participants were from poor socio-economic backgrounds. In both groups, adherence to breastfeeding recommendations was low with suboptimal dietary diversity. We noted a high rate of sugar- and salt-containing snacks given from a young age. The HU group had poorer anthropometric and nutritional indicators not explained by nutritional factors alone. However, alcohol and tobacco use was much higher amongst the HU mothers.
Adherence to breastfeeding recommendations was low. Ethnicity and cultural milieu may have influenced feeding choices and growth. Further research is needed to understand possible reasons for the poorer nutritional and anthropometric indicators in the HU group.
Observational studies show that exclusive breastfeeding in the early months of life and continued breastfeeding with timely transition to high-quality complementary foods deliver physiological and economic benefits to mothers and maximise nutrient intake, growth, development and survival of children.
In the absence of interventions, 5% – 20% of infants born to HIV-infected mothers acquire HIV through breastfeeding.
Optimal feeding practices are crucial for the nutritional status, health and survival of infants.
The success of the PMTCT programme has decreased HIV infection in infants, conversely increasing the number of HEU infants. To date, there has been no comparison of feeding practices between HEU and HIV-unexposed (HU) children in the Western Cape. In this study, we explored feeding practices and nutritional status in HEU and HU children over 12 months. Participants had been recruited for a pilot study of innate immune abnormalities in 2009, when antenatal dual ART was provided unless combination ART was indicated in the mother for either WHO stage 3 or 4 disease or a CD4 count at below 200 cells/mL.
HIV-infected and -uninfected mothers and their infants were recruited from the postnatal maternity wards of Tygerberg Academic Hospital, which serves patients from lower socio-economic communities in the Western Cape. The aim of the study was to compare infectious disease morbidity and vaccine responses in HEU and HU infants over 24 months.
Nutritional information was obtained from the caregiver, generally the mother. Weight, length and head circumference were recorded at each visit. Sociodemographic questions were included in the nutrition questionnaire. Caregivers were asked to answer yes or no to questions regarding nonnutritional foods, that is, salty snacks and sugar-containing snacks and drinks, given to the infant and the current alcohol and tobacco (smoking) use of the caregiver (the mother).
We used simple rapid-assessment techniques with the WHO indicators
The proportion of children who were put to the breast within 1 hour of birth.
The proportion of infants 0–5 months of age who were fed exclusively with breast milk.
The proportion of children 12–15 months of age who were fed breast milk.
The proportion of infants 6–8 months of age who received solid, semisolid or soft foods.
The proportion of children 6–23 months of age who received foods from four or more food groups per day. The seven foods groups used for this indicator were grains, roots and tubers, legumes and nuts, dairy products (milk, yoghurt and cheese), flesh foods (meat, fish, poultry and liver or organ meats), eggs, vitamin A–rich fruits and vegetables and other fruits and vegetables.
The proportion of children who were ever breastfed.
The proportion of children 0–23 months of age who were fed with a bottle, regardless of whether the infant was breastfed.
Proportion of non-breastfed children 6–23 months of age who received at least two milk feedings per day.
The WHO Anthropometric calculator application (version 3.2.2, January 2011) was used for
Participants were recruited over a 16-week period from March to June 2009. Forty-seven mother–infant pairs (25 HEU and 22 HU infants) participated in this nutritional substudy (
Sociodemographic characteristics of HIV-exposed uninfected and HIV-unexposed infants at enrolment in nutrition study at 6 months of age.
Characteristics | HEU ( |
HU ( |
||||
---|---|---|---|---|---|---|
% | IQR | % | IQR | |||
Males | 7 | 28 | - | 12 | 55 | - |
Ethnicity: Mixed race people | 6 | 24 | - | 17 | 77 | - |
Ethnicity: White people | 0 | - | - | 1 | 5 | - |
Ethnicity: Black people | 19 | 76 | - | 4 | 18 | - |
Inhabitants per household median | 6 | - | 3−5 | 4 | - | 4−7 |
Children under 13 years median | 2 | - | 1−2.5 | 2 | - | 1−3 |
Number employed in household median | 1 | - | 1 | 1 | - | 1−2 |
Running water within house | 11 | 44 | - | 10 | 50 | - |
Ablution within house | 12 | 48 | - | 10 | 50 | - |
Mothers using alcohol | 1 | 4 | - | 5 | 23 | - |
Mothers smoking | 7 | 28 | - | 16 | 73 | - |
HEU, HIV-exposed uninfected children; HU, HIV-unexposed children; IQR, interquartile range.
The HEU children were mainly Xhosa (76%) and HU were mainly mixed race (77%). Occupation density and number of young children in the households were similar. Nearly half of the households had running water and ablution facilities inside the house. More HU mothers smoked (73% versus 28%) and used alcohol (23% versus 4%).
In the HEU group, only one mother initiated breastfeeding and was still breastfeeding at 18 months (
Feeding practices by World Health Organization indicators 19 of HIV-exposed uninfected and HIV-unexposed children.
WHO indicator | Study visit | HEU | HU | ||
---|---|---|---|---|---|
% | % | ||||
Ever breastfed | - | 1 | 4 | 22 | 100 |
Early initiation of breastfeeding | Confirmed | 0 | - | 12 | 55 |
Not initiated early | 1 | 100 | 6 | 27 | |
Unknown | 0 | - | 4 | 18 | |
Continued breastfeeding at | 6 months | 1 | 4 | 13 | 59 |
12 months | 1 | 5 | 13 | 62 | |
18 months | 1 | 6 | 11 | 52 | |
Exclusive breastfeeding at 6 months | - | 0 | - | 0 | - |
Adequate milk frequency | 6 months | 24 | 100 | Not applicable | - |
12 months | 16 | 80 | 6 | 100 | |
18 months | 15 | 83 | 8 | 80 | |
Bottle-fed | 12 months | 20 | 95 | 13 | 72 |
18 months | 14 | 93 | 15 | 79 | |
Food introduction at 6 months | - | 19 | 76 | 21 | 96 |
Minimum dietary diversity | 6 months | 5 | 20 | 10 | 46 |
12 months | 13 | 65 | 10 | 56 | |
18 months | 11 | 61 | 14 | 67 | |
Nonnutritional foods |
6 months | 8 | 32 | 15 | 68 |
12 months | 12 | 52 | 20 | 100 | |
18 months | 18 | 100 | 21 | 100 |
HEU, HIV-exposed uninfected children; HU, HIV-unexposed children.
HEU: 6 months:
Nonnutritional foods (salty snacks and sugar-containing snacks and drinks).
No information was available on bottle-feeding at 6 months because of misinterpretation of the survey question. However, all but one HEU infant were assumed to bottle-feed, as only one mother was breastfeeding. Almost all HEU infants were bottle-fed from 12 to 18 months. Amongst the HU infants, 72% and 79% were bottle-fed at 12 and 18 months.
At 6 months, 96% of HU and 76% HEU infants had solid, semisolid or soft foods introduced. At 6 months, 46% of HU and 20% HEU had minimum dietary diversity. By 12 months, it was 65% for HEU and 56% for HU and by 18 months it was 61% and 67%, respectively, for HEU and HU.
Sixty-eight percent of HU and 32% of HEU infants were fed nonnutritional foods at 6 months increasing to all HU and about half the HEU infants at 12 months. By 18 months, all infants were receiving nonnutritional foods.
The HU group had poorer anthropometry (
Anthropometry of HIV-exposed uninfected and HIV-unexposed infants.
Months | HEU median | IQR | HU median | IQR | |
---|---|---|---|---|---|
Weight/age | 6 | −0.07 | −0.67 to 0.92 | −0.96 | −1.52 to 0.32 |
12 | 0.04 | −0.61 to 1.15 | −0.39 | −1.24 to −0.18 | |
18 | 0.15 | −0.53 to 1.33 | −0.31 | −1.47 to 0.12 | |
Length/age | 6 | −0.4 | −1.07 to 0.09 | −0.93 | −2.30 to 0.07 |
12 | −0.09 | −0.8 to 0.73 | −0.39 | −1.82 to 0.71 | |
18 | −0.29 | −0.72 to 0.64 | −0.94 | −1.64 to 0.36 | |
Weight/length | 6 | 1.09 | −0.37 to 1.56 | 0.08 | −0.78 to 0.87 |
12 | 0.17 | −0.46 to 1.27 | −0.34 | −1.04 to 0.81 | |
18 | 0.61 | −0.33 to 1.21 | −0.27 | −1.02 to 0.62 | |
Head circumference/age | 6 | 0.53 | 0.02 to 1.07 | −0.32 | −1.05 to 0.15 |
12 | 0.37 | −0.02 to 1.11 | −0.66 | −1.22 to 0.34 | |
18 | 0.54 | −0.50 to 1.15 | −0.42 | −0.93 to 0.51 |
HEU, HIV-exposed uninfected children; HU, HIV-unexposed children; IQR, interquartile range.
Nutritional indicators of HIV-exposed uninfected and HIV-unexposed infants.
Months | Study group | Underweight | Stunted | Wasted | ||||
---|---|---|---|---|---|---|---|---|
% | % | % | ||||||
6 | HEU | 25 | 0 | - | 2 | 8 | 0 | - |
HU | 22 | 2 | 9 | 6 | 27 | 1 | 5 | |
12 | HEU | 23 | 0 | - | 0 | - | 1 | 4 |
HU | 21 | 3 | 14 | 4 | 19 | 0 | - | |
18 | HEU | 18 | 0 | - | 0 | - | 0 | - |
HU | 21 | 2 | 10 | 4 | 19 | 0 | - |
HEU, HIV-exposed uninfected children; HU, HIV-unexposed children.
In this small study, we documented detailed feeding history in HEU predominantly Xhosa infants and HU predominantly mixed race infants. In both groups, adherence to breastfeeding recommendations was low and there was suboptimal dietary diversity. However, there were significant differences between groups in the practices and outcomes.
Breastfeeding occurred in all HU and in one HEU infant(s). The mainly formula-fed HEU infants had a significant decrease in milk frequency after 6 months, coinciding with no access to free formula after this age. We noted a high rate of sugar- and salt-containing snacks given from a young age in both groups. The HU group had poorer anthropometric and poorer nutritional indicators not explained by nutritional factors alone. Alcohol and tobacco use were much higher amongst the HU mothers. All these factors (ethnicity, smoking and alcohol use) may have played a role in the difference in anthropometric and nutritional indicators between the two groups. Because of these confounding factors and small sample size, statistical analyses were not included.
The rate of breastfeeding was extremely low in HEU infants, possibly because free formula milk through public health facilities for the first 6 months of life for all HEU was standard of care at the time. All HU infants were initiated on breastfeeding, whilst the provincial average was 87.1% in 2003–2004,
In this study, no infant was exclusively breastfed
Continued breastfeeding at 1 year was similar to the national proportion.
Adequate milk frequency for HEU infants decreased significantly from 100% at 6 months to 80% at 12 and 18 months. This may have been due to the provision of free formula milk to all HEU infants for the first 6 months of life at the time of the study. Poorer caregivers may struggle to pay for formula milk thereafter
The proportion of infants bottle-fed in the study exceeded national figures; 72% of HU infants at 12 months compared to 40% nationally at 12–15 months. Furthermore, 79% of this group were bottle-fed at 18 months compared to 27% at 16–19 months nationally.
Early introduction of complementary food is common in many developing countries
Dietary diversity was inappropriate during the first few months after weaning. Dietary diversity is essential as inadequate complementary feeding at 6 months of age is associated with impaired growth and increased stunting during the next 12 months.
All the HU were given snacks and/or drinks containing sugar and salt at 12 months and HEU infants by 18 months. The widespread use of such goods at a young age may increase risk of elevated blood pressure
The HU group had poorer nutritional and anthropometric indicators than the HEU group, despite the higher infectious morbidity already described in the HEU group.
A much higher proportion of the mothers in the HU group (23% versus 4%) reported alcohol use. Excessive alcohol consumption remains a serious social and public health problem in the Western Cape. The prevalence of risky drinking (more than two drinks per day for women) is higher in the Western Cape Province than in all the other provinces (9% compared with ≤ 5%), with mixed race women having higher levels than other communities (12.6% compared with ≤ 2%).
In our study, 73% of the mothers of HU infants compared to 28% of the HEU group reported smoking. The Western Cape Province has the highest prevalence of smoking of all the provinces: 44.7% of men and 27% of women including a large proportion of pregnant women.
This study had a small sample size with various confounding factors in both groups. Interviewer standardisation and guidelines for use of questionnaires were not strictly controlled and some misinterpretation of the questionnaire is possible. In our opinion, even though the data are from 2009, it remains relevant to feeding practices and social issues impacting on healthy growth in the current social and economic climate.
The study found disturbing information regarding feeding patterns and growth in two different cultural groups with similar economic surroundings. Infants in both groups received nonnutritional foods with high sugar and salt content, emphasising a general lack of nutritional awareness. More education and more counselling are imperative. Further research is needed to understand reasons for the poorer nutritional and anthropometric indicators in the HU group. The role of smoking and alcohol use during pregnancy and breastfeeding and other potential confounders require further investigation.
The authors thank students of the Hochschule Niederrhein, University of Applied Sciences, Faculty of Food, Nutrition and Hospitality Sciences, Germany, who developed the questionnaire. The authors acknowledge the dedication shown by Sister S. Sylvester who helped with administering of questionnaires, performed anthropometric measurements and co-ordinated follow-up visits and the participants and their mothers.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
M.E.R. was the primary author of the article. M.C. and M.F.C. made significant conceptual contributions. M.M.E. was the study leader and responsible for the project protocol and gave valuable comments.