Module 5: Breastfeeding and Formula

Advantages of Breastfeeding

Breastfeeding is one of the most effective ways to ensure child health and survival. Failure to breastfeed during the first six months of life contributes to over a million preventable child deaths each year.(1) There are well established benefits to the mother and to the child's growth, mental development, and immunological protection.

The World Health Organization recommends that an infant should be exclusively breastfed for the first six months, and the child should continue breastfeeding for two years or more with supplemental foods. For the mother, exclusive breastfeeding often induces a lack of menstruation, which is a natural (though not fail-safe) method of birth control. Breastfeeding also reduces risks of breast and ovarian cancer later in life, helps women return to their pre-pregnancy weight faster, and lowers rates of obesity.(2)

Globally less than 40% of infants under six months of age are exclusively breastfed. Increasing this rate can be achieved by improving breastfeeding support for mothers and families, and this could save many lives. For example, 13% of under-5 deaths could be prevented if all infants were breastfed – more than any other preventative intervention.(3)

While breastfeeding tends to have a net-positive effect on infant and maternal health, there are some potential disadvantages. Breastfeeding puts a strain on the mother's nutrients, and breastfeeding women must be careful about their own nutrition and continue to avoid certain foods and limit the intake of others. Furthermore, as outlined below, the transmission of HIV through breast milk poses serious risks to infants and mothers.

HIV and Breastfeeding

The recent recognition that non-exclusive breastfeeding may transmit HIV-1 to the infant has resulted in the avoidance of breastfeeding by infected women in the industrialized world.(4) The vertical transmission of HIV (also known as mother to child transmission or MTCT) in South Africa ranges from 19 to 36%, depending on whether the child is breastfed or not.(5) In 2000, the South African government estimated that about 75,000 infants were born with HIV-1 infection in South Africa.(6) Research suggests that about half of these infections could have been prevented if short-course antiretroviral treatment had been available.(7)(8)(9)

The transmission of HIV-1 through non-exclusive breastfeeding accounts for approximately 44% of the total mother-to-child-transmission rate and remains a pressing issue among poor communities in the world.(10)

The avoidance of breastfeeding is often not a realistic option for women in these regions because formula may be unavailable or prohibitively expensive and research in Africa has shown that after counseling on feeding choices, a large proportion of HIV-infected pregnant women breastfed their babies.(11)

One study observed that the risk of HIV infection by six months among exclusively breastfed children was no different from the infection rate among children who were never breastfed.(12) Specifically, the results demonstrate that infants on exclusive breastfeeding had no excess risk of mother-to-child-transmission of HIV-1 in the first 6 months when compared with infants who were not breastfed at all but given formula and other foods.(13) These results suggest that the vertical transmission of HIV-1 through breast milk is dependent on the pattern of breastfeeding and that exclusive breastfeeding may not raise the risk of mother-to-child transmission of HIV-1.

Ultimately, in order to reduce mother to child transmission of HIV in low- and middle-income countries, the provision of affordable antiretroviral drugs should be combined with educational and public health efforts to reduce the risk of transmission of the virus.

Donated Baby Formula

A controversy exists around whether HIV-infected women in low- and middle-income countries should choose formula or breastfeeding for their infants. While exclusive formula feeding eliminates the risk of HIV transmission via breast milk, it is associated with increased risk of mortality, whereas breastfeeding has multiple benefits but non-exclusive breastfeeding may increase the risk of HIV transmission.

“The case against providing free or subsidized formula to HIV-infected mothers is based on the following: it exacerbates disadvantages of formula feeding; compromises free choice; targets beneficiaries erroneously; creates a false perception of endorsement by health workers; compromises breastfeeding; results in disclosure of HIV status; ignores hidden costs of preparation of formula; increases mixed breastfeeding, which is an unsatisfactory method for all women; requires organization and management of programs that are complicated and costly; and finally increases the ‘spill-over’ effect into the normal breastfeeding population.”(14)

Dependency, Malnutrition, Illness (15)

If a mother uses formula, she usually reduces or stops breastfeeding. This may create a problem if the donated formula runs out. The breasts decrease their milk production if not stimulated for a sustained period of time, causing the mother to have problems resuming breastfeeding because she has decreased or even ended her own milk production.

This situation puts the baby at risk for malnutrition if the parents are unable to afford baby formula or substitute foods. The cost of purchasing formula in low- and middle-income countries is high, and purchasing formula can quickly become a financial hardship or impossibility. “If a family cannot afford to purchase enough formula they may either water down the formula to make it stretch farther and thus deprive their child of adequate nutrition, or they might try a substitute like powdered milk or sweetened and diluted cow’s milk.”(16)

Furthermore, reliance on formula can have unintended consequences that include serious illness.(17) In both the Global North and the Global South, formula-fed infants have an increased risk of gastrointestinal infections and respiratory infections compared to their breastfed peers.(18)(19)

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(1) World Health Organization. (August 2017). "10 Facts on Breastfeeding."

(2) Ibid.  

(3) Maclaine, A. (2007). Infant Feeding in Emergencies: Experiences from Lebanon. London: Humanitarian Practice Network.

(4) Coutsoudis A, Coovadia H, Pillay K, and Kuhn L. Are HIV-infected women who breastfeed at increased risk of mortality? [Letter] AIDS 2001;15,5:653-655.

(5) A Coutsoudis, K Pillay and L Kuhn et al., Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa, AIDS 15 (2001), pp. 379–387.

(6) Abdool Karim AS, Abdool Karim Q, Adhikari M, Cassol S, et al. Vertical HIV transmission in South Africa: Translating research into policy and practice. Lancet. 2002; 359, 9311:992-3.

(7) LA Guay, P Musoke and T Fleming et al., Intrapartum and nconatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial, Lancet 354 (1999), pp. 795–802.

(8) N Shaffer, R Chuachoowong and P Mock et al., Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomized controlled trial, Lancet. 353 (1999), pp. 773–780.

(9) Ibid.

(10) Nduati R, John G, Mbori-Ngacha D. et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA. 2000, 283: 1167 -1174.

(11) Saba J. Interim analysis of early efficacy of three short ZDV/3TC combination regimens to prevent mother-to-child-transmission of HIV-1: the PETRA trial. 6th Conference on Retroviruses and Opportunistic Infections. Chicago, 31 January-4 February, 1999.

(12) Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant feeding patterns on early mother-to-child-transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet. 1999, 354: 471 -476.

(13) Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai WY, Coovadia HM; South African Vitamin A Study Group. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: Prospective cohort study from Durban, South Africa. AIDS. 2001;15, 3 :379-87.

(14) Coutsoudis A, Goga AE, Rollins N and Coovadia HM on behalf of the Child Health Group. Free formula milk for infants of HIV-infected women: Blessing or curse? Health Policy and Planning. 2002; 17, 2: 154-160.

(15) Schimmelpfennig, Saundra. "Four Reasons to NOT Donate Baby Formula Overseas." 11 March 2011.

(16) Ibid.

(17) Bentham, Martin. "Thousands of Haiti Babies ‘could Die from Milk Donations’." London Evening Standard. 28 Jan. 2010.

(18) Cesar, G.V., et al. 1987. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet. 330: 319-322.

(19) Stuebe, A. 2009. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol. 2:222-231.