ORIGINAL

Niger J Paed 2014; 41 (1):64 - 69

Olatona FA

Ginigeme ON

Roberts AA

Amu EO

Infant feeding practices in the first

six months of life among HIV

positive mothers attending Teaching

Hospitals in Lagos, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i1,12

Accepted: 2013

Abstract Background: In the

absence of any interventions,

practiced by majority 73.5%

(n=147) of the respondents, 18.5%

(n=37) practiced Exclusive Breast-

feeding (EBF) while 8% (n=16)

practiced mixed feeding. Poor

knowledge of infant feeding op-

tions and feeling that EBF was not

enough in the first six months of

life were associated with EFF

Olatona FA⁽

)

5

-20% of infants born to HIV-

Ginigeme ON, Roberts AA

Department of Community Health,

Lagos University Teaching Hospital /

College of Medicine, University of

Lagos. Nigeria

infected women will be infected

through breastfeeding.

Objectives: This study determined

the pattern of infant feeding in the

first six months among HIV posi-

tive women attending Teaching

Hospitals in Lagos.

Methods: It was a cross sectional

descriptive study. All mothers

who were registered between July

and September 2012 in the

Email: folaton@gmail.com,

Tel: +2348033163216

(

p = 0.04) and mixed feeding

Amu EO

(p = 0.01) respectively.

Department of Community Medicine,

Ekiti State University Teaching

Hospital, Ekiti State, Nigeria.

Conclusion: Although majority of

the respondents practiced

exclusive formula feeding, a

sizeable proportion still practiced

mixed feeding. Strengthening of

counseling sessions at

‘Prevention of mother to child

transmission’ (PMTCT) clinic

were interviewed (n=200).

Pre-tested interviewer adminis-

tered structured questionnaire was

used to collect data and analysis

was done using Epi-info software.

Chi-square and Fischer exact tests

were used to determine associa-

tions and p-value was set at 0.05.

Results: Many of the respondents,

PMTCT clinic, encouragement of

exclusive breastfeeding with

antiretroviral drugs would help

reduce the prevalence of mixed

feeding and hence the risk of

mother to child transmission

of HIV.

4

6.5% (n=93) were within the age

Key Words: Infant feeding

range of 30 – 34. Exclusive

formula feeding (EFF) was

practices, Mothers, HIV Positive

Introduction

(40%), diseases which occur more frequently and with

more severe cons₃equences when infants are not exclu-

sively breastfed. The HIV epidemic threatens the child

survival and development gains of the past decades.

Human immunodeficiency virus (HIV) causes acquired

immunodeficiency syndrome (AIDS) a condition in hu-

mans in which progressive failure of the immune system

allows life-thre₁atening opportunistic infections and can-

cers to thrive. Major routes of transmission are unsafe

sex, contaminated needles and transmission from an

infected mother to her baby during pregnancy, at birth

and through breast milk.

In the absence of any interventions, 5-20% of infants

born to HIV-i₄nfected women will be infected through

breastfeeding.

World Health Organization estimates

that 150,000 babies around the world are infected with

HIV via breast milk each year. Research has shown that

infants exclusively breastfed for 3 months or more had

no excess risk of HIV infection over 6 months than

those never breastfed and Exclusive breastfeeding (EBF)

carries a lower risk of HIV infection than mixed feeding.

The highest rate of infection was found among babies

Sub-Saharan Africa remains the worst-affected region,

with 22.5 million people currently living with HIV (67%

of the global total) and 4.4 million children infected. In

Sub-Saharan Africa, HIV has resulted in the death of 3.2

million children and 90% of the world's 16.6 million

children orphaned by HIV. Among newborn infants test-

ing HIV-positive within 48 hours after birth, approxi-

mately 50% die within six months, primarily due to in-

fectious diseases such as pneumonia (75%) and diarrhea

5

given a mixed diet. Replacement feeding/infant

formula with the avoidance of breast feeding is the only

100 percent effective way to prevent mother-to-child

transmission (MTCT) of HIV after birth. Unfortunately,

this might not be totally possible in some societies

6

5

especially low socioeconomic areas because of cost, the

risk of infant mor₆bidity and mortality from other ill-

nesses and stigma.

ported that they were counseled on both EFF and EBF

and asked to make a choice, while 43.5%, (n=87) were

counseled on EFF and 17.5%, (n=35) on EBF.

In developed countries, Mother to Child Transmission

rates have fallen to as low as 2% due to the introduction

of routine HIV testing among antenatal mothers and the

provision of antiretroviral drugs (ARV) during preg-

nancy and breastfeed₇ing, elective caesarian delivery and

safe infant feeding; as against 25% without such opti-

Majority of the respondents, 73.50% (n=147) practiced

EFF, while 18.5% (n=37) practiced EBF and 8% (n=16)

practiced mixed feeding in the first 6months of infant’s

life. Majority 62.5% (n=10) of those who practiced

mixed feeding attributed it to breast-milk not being

enough while only 18.75% (n=3) of them said it’s due to

ignorance about their HIV status. (Table 1)

8

mal treatment.

In sub-Saharan Africa however, these interventions are

not available to the majority. In Nigeria, EBF is pro-

moted but adequate counseling is given to the mother

and choice of infant feeding option suitable for her is

made.

Table 1: Infant feeding pattern among respondents within the

first six (6) months of life

Feeding pattern and reasons for mixed feed-

ing

Freq Percent

(%)

This study assessed the patterns of infant feeding among

HIV positive mothers attending teaching hospitals in

Lagos, Nigeria.

Feeding Pattern in the first 6months (n=200)

Exclusive Formula feeding

147

73.5

Exclusive Breast feeding

Breast feeding, formula feeding and water

Breast feeding and water

37

7

6

18.5

3.5

3

Others e.g. pap

3

1.5

Materials and methods

Reason for mixed feeding (n=16)

Breast milk not enough

10

3

62.5

18.75

The study was conducted in two (2) Teaching Hospitals

in Lagos. It was a descriptive cross sectional study

among HIV positive mothers with babies between

Pressure from family/friends

Ignorance pertaining to HIV status/ feeding

options

3

18.75

2

weeks and 18months of age attending HIV/AIDS treat-

Most of the respondents who did not breastfeed

57.50%) chose not to do so because they were worried

about transmitting the virus to their babies while only

6.5 % (n=33) followed their doctors’ advice not to

ment centers (PMTCT clinic) in the Teaching Hospitals.

All babies that were registered in the exposed babies’

clinic in the two Teaching Hospitals between July and

September 2012 (200) were interviewed.

(

1

breastfeed. Fig 1

Pretested interviewer administered questionnaires were

used to collect data between July and September 2012

with the assistance of three medical students (500 level)

and three research assistants (undergraduates) who were

trained for the purpose. The questionnaire was divided

into four sections. Section A collected socio demo-

graphic data. Section B collected data regarding knowl-

edge of infant feeding options, section C collected data

on attitude towards infant feeding options and section D

collected data on infant feeding practices.

Fig 1: Respondents reasons for not breast feeding

Ethical approval was obtained from the Health Research

and Ethics committee of LUTH and LASUTH. A writ-

ten informed consent was obtained from the mothers and

privacy and confidentiality were assured.

Data were analyzed using Epi-info soft ware. Chi square

was used to determine associations and p value < 0.05

was considered statistically significant. Fischer’s exact

values were calculated where chi square was not valid.

*

multiple responses allowed

Expensive cost of purchasing formula milk was a prob-

lem faced by many of the respondents (42.50%, n=85),

while 11.5% (n=23) faced complaints from relatives.

Among those that practiced EBF, 18.9% (n=7) felt the

breast-milk was not enough for the child while 13.5

(

n=5) had pressures from relatives to give other feeds

Table 2).

Results

The respondents were aged between 20-42 years; the

mean age being 31.2 (3.8) years. Majority of the respon-

dents (95.5%, n=191) were married. The ages of the

babies ranged from 2 weeks to 18 months and a mean

age of 5.04±4.33SD months. Only 34.5 %, (n=69) re-

The choice of infant feeding option was determined per-

sonally by majority of the respondents (67%) (n=135)

while almost one quarter (21%, n=42) just followed the

doctor or nurse's counsel. Among the respondents prac-

ticing formula feeding, most of them (89.8%.n=132)

6

prepared the formula using bottled or boiled water but

most of them (80.95%, n=119) used feeding bottle to

feed. Only 7.5% (n=11) of the mothers used cup and

spoon to feed their babies.

the respondents who did not agree with EBF being

enough in the first six months of life (74.5%) practiced

EFF (Table 4).

Table 4: Association between certain variables and infant

Table 2: Challenges encountered with infant feeding options

feeding practices

Challenges with EFF (n=147)

Freq

Percent

Variable EBF(n=37)

Freq (%)

Mixed feeding EFF

(n=147)

Freq(%)

(n=16)

Freq (%)

X2 p value

6.39 0.04

Expensive cost of purchasing formula

No challenge

85

34

23

4

42.5

17

11.5

2

Pressure from relatives/friends

Problem with working and feeding

No regular supply of formula milk

Challenges with EBF (n=37)

No challenge

Crack/ sore nipples/ill mother

Feeling that breast milk is not enough

Pressure from relatives to add other feeds

Others eg problem with working and

feeding

Knowledge about infant feeding

Good

Poor

26(24.5)

11(11.7)

6(5.7)

10(10.6)

74(69.8)

73 (77.7)

1

0.5

Knowledge about HIV transmission through breastfeeding

14

9

7

37.84

24.32

18.92

13.51

Yes

No

26(15.5)

11(34.4)

14(8.3)

2(6.3)

128(76.2)

19(59.4)

Fischer’s p

0.05

5

Attitude to EBF being enough in the first 6 months

Yes

No

33(21.57)

4(8.51)

8(5.23)

8(17.02)

112(73.2)

35(74.47)

2

5.41

Fischer’s p

0

.01

Most of the mothers, 54% (n=108) started ARV’s before

and continued till after pregnancy, 33.5% (n=67) started

during and continued till after delivery, while 5% never

took ARV’s. Majority 84.5% of the babies (n=169)

started receiving ARV’s immediately after delivery and

continued for at least eight weeks but 8% were never

given ARV. (Table 3)

Discussion

Almost all the respondents (95.5%) received a form of

counseling on infant feeding options though almost half

were counseled towards EFF. This is similar to a study

in Ghana which showed that 83% of the HIV positive

mothers interviewed had received counseling on World

Health Organization (WHO)’s recommended feeding

Table 3: Distribution of respondents according to practices

related to infant feeding

Person responsible for decision making on infant

feeding

Freq

Percent

9

Self

Doctor/nurse

Spouse

Others

135

42

18

3

67.5

21

9

1.5

1

options during their antenatal or post natal services. In

another study in South Africa, ₀94.4% received counsel-

1

ing on infant feeding options. This is a good steep in

Family member

2

the right direction for Africans since counseling has

been shown to aid good infant feeding practice among

mothers who are HIV positive.

Method of formula feeding (n=147)

Feeding bottle

Feeding bottle, cup and spoon

Cup and spoon

119

17

11

80.95

11.56

7.48

The high rate of EFF (73.5%) was in agreement with

results obtained in Ibadan, Nigeria₁where choice of in-

Water used for formula preparation

Boiled tap water/bore hole/pure sachet

Bottled water

Pure/sachet water/bore hole

Boiled well water

1

69

59

15

4

46.94

40.14

10.2

fant feeding was 93.5% for EFF. It has been shown

12

that HIV positive mothers are willing to choose EFF

and have the tendency₁₃to stop breastfeeding once they

2.72

Antiretroviral drugs taken by mother (n=200)

Have been on ARV’s before and after pregnancy

Started during pregnancy and continued

Never did

knew their HIV status.

108

67

10

5

54

33.5

5

2.5

This preference for EFF could be responsible for the rate

of EBF (18.5%) which was much lower than the rates

obtained in some other African c₁o₀untries such as Kenya

Started after delivery

Only once before delivery

Antiretroviral drugs taken by child (n=200)

Immediately after delivery and continued for at least

1

4

(

35%) , South Africa (35.6%)

, Northwest Ethiopia

15

9

83.7%) , Ghana (100%). Higher level of awareness

8

Never did

Started days after delivery

Only once after delivery

Continued throughout breast feeding

weeks

169

16

8

5

2

84.5

8

4

2.5

1

about the current recommendation of WHO for feeding

HIV positive infants in the other countries may be re-

sponsible for higher prevalence of EBF but since the

prevalence of EBF amongst the general population in

Nigeria is 13%, one m₁a₆y not expect a higher rate among

HIV positive mothers.

A higher proportion of those who had poor knowledge

of infant feeding options (77.7%, n=73) practiced EFF.

There was a significant association between knowledge

of infant feeding options and the feeding option adopted

The proportion of mothers who practiced mixed feeding;

an undesirable practice within the first six months of age

(

p=0.04). However, there was no significant association

(

8%), was in keeping₅ with results of studies conducted

1

between knowledge about HIV transmission through

breastfeeding and the feeding option practiced (p=0.05).

There was a significant relationship between attitude to

EBF and the feeding practice adopted (p=0.01). Most of

in Ethiopia (10.5%) and South Africa South Africa

(

12.4%). Majority of those who practiced it did so be-

cause they believed that breast milk was not enough;

though some yielded to pressure from family and friends

6

7

1

5, 25

while others were not aware of their HIV status and the

feeding options for exposed babies on time. The result is

in agreement with another study where babies becoming

increasingly hungry (25%) was the major reason for

In consonance with other studies,

most of the re-

spondents initiated ARV drugs before delivery. More-

over, most of their babies took ARVs immediately after

delivery and continued for at least 8 weeks after. This

means that EBF with use antiretroviral drugs is a sus-

tainable method among most of the HIV positive moth-

ers attending teaching hospitals.

Poor knowledge of infant feeding options and negative

attitude to adequacy of EBF in the first 6 months were

significantly positively associated with EFF respec-

tively. This means that if the women are adequately

counseled and have better level of knowledge of safe

infant feeding options and positive attitude, they are

likely to choose to breastfeed.

1

3

mixed feeding. Many mothers and caregivers tend to

believe that breast milk is not enough for children’s

growth and tend to add other items. A certain study in

Lagos, showed that as many as 33.6% of those who did

not practice E₁B₇F failed to do so because they added in-

fant formula. Mixed breast feeding has been shown to

18

damage the intestinal lining of the gut in infants, lead-

ing to an in₁c₉r_, e₂₀ased risk of HIV transmission through

breast milk.

Apart from mixed feeding, another strong determinant

for HIV transmi₂s₁sion through breast milk is duration of

The study findings are limited in terms of overall gener-

alization since many of the infants were below six

months and the mothers could have changed the feeding

pattern before six (6) months of age. Moreover, since the

study was health institution based, some respondents

who received counseling on recommended way of infant

feeding practice might have responded correctly as ex-

pected and thereby reduced the estimate of the propor-

tion that practiced mixed feeding.

breastfeeding.

Early, abrupt cessation of breast-

feeding by HIV-infected women in a low-resource set-

ting does not improve the rate of HIV-free survival

among children born to HIV-infe₂c₂ted mothers and is

harmful to HIV-infected infants. The World Health

Organization recommends that when ARVs are not

available, mothers should be counseled to breastfeed

exclusively for the first six months of life and continue

breastfeeding thereafter unless environmental and social

circumst₂a₃nces are safe for and supportive of replacement

feeding.

Conclusion

Most of the mothers who did not breast feed chose not

to do so because they were worried about transmitting

the virus to₁₁ their babie₂s₄. This is similar to other studies

in Ibadan and India where majority of the mothers

chose not to breast feed in order to prevent transmission

of HIV. Unfortunately many of those w₉ho chose EFF in

this study and another study in Ghana had challenges

with high cost of purchasing formula milk. This could

have led to over-dilution of the milk which would com-

promise the nutritional status of the child and lead to

morbidity and mortality. Women may inadvertently en-

danger their infants' health by practicing formula feed-

ing in an attempt to prevent HIV transmission through

breast milk.

Most participants practiced Exclusive Formula Feeding

or Exclusive breastfeeding but mixed feeding was still

recorded. Cost of purchasing formula milk and bottle

feeding were major challenges to safety of formula feed-

ing whereas more of the respondents who practiced EBF

experienced no challenge. Replacement feeding is there-

fore not affordable and safe among the respondents. EFF

was associated with poor knowledge of infant feeding

options and attitude to adequacy of EBF. Information

concerning post-natal HIV transmission and counseling

about safe infant feeding options offered to HIV positive

women should be adequate and clear. Further studies

would be required to determine and compare the mor-

bidity and mortality rates among babies who are exclu-

sively breastfed and formula fed.

Among the respondents practicing formula feeding, ma-

jority used bottled water or boiled their tap/borehole/

well/sachets water to prepare the infant formula. This is

in consonance with the report of another study in Benin,

Nigeria where most of the mothers boile₁₃d their water

before using it to prepare formula milk. This shows

that most of the women have been counseled on the im-

portance of clean/treated water in the preparation of in-

fant formula to prevention infection and they complied

with the counsel. However, most of the mothers in this

study used feeding bottle while only 7.5% used cup and

spoon to feed their babies. This is much lower than the

result from the Benin study which showed₃that 27.1% of

Authors’ contributions

Ginigeme ON and Olatona FA: Participated in the

conceptualization, design, analysis and interpretation of

data.

Olatona FA: Drafted the manuscript for important intel-

lectual content and reviewed it.

Roberts AA and Amu EO: Participated in drafting and

critical review of the manuscript. All authors read and

approved the final manuscript.

1

the babies were fed with cup and spoon. The feeding

Conflict of interest: None

Funding: None

bottle may not be properly sterilized and leads to other

infections which may increase the risk of morbidity and

mortality in the children. This means that replacement

feeding is not safe among these participants.

6

8

Acknowledgements

nal, is not under consideration by any other journal and

has not been previously published. All copyright

ownership of the manuscript entitled (Infant Feeding

Practices in the first 6 months among HIV positive

mothers in Teaching Hospitals in Lagos) is hereby trans-

ferred to the publishers of the Nigerian Journal of Paedi-

atrics.

The authors acknowledge the staffs of APIN clinic

LUTH and LASUTH for their great assistance during

data collection.

Certification

Dr Foluke Adenike Olatona

The undersigned authors certify that the article is origi-

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