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Debate to Focus on Pros, Cons of Breastfeeding by HIV-Positive Mothers :

September 15, 2017

Editor's note: The 2017 AAP National Conference & Exhibition will take place from Sept. 16-19 in Chicago.

For years, HIV-positive mothers in the U.S. were advised against breastfeeding so they would not pass the virus to their babies. The result: Postnatal transmission rates have dropped to around 1%.

This reduction and the growing evidence of breast milk’s benefits have convinced some experts that it is appropriate for many HIV-positive mothers to breastfeed their infants.

The issue will be debated during a point-counterpoint session titled “Should HIV-Positive Mothers Be Encouraged to Breastfeed in Well-Resourced Countries? (D4010)” from 8:30-9:30 am Tuesday in McCormick Place West, W183 C.

Robert Lawrence, MD, FAAP, a member of the Academy of Breastfeeding Medicine, will argue in favor of breastfeeding by HIV-positive moms, while Ellen Chadwick, MD, FAAP, chair of the AAP Committee on Pediatric AIDS, will take the con position.

“I do think that there are clearly scenarios where breastfeeding in the United States for an HIV-exposed infant and an HIV-positive mom could be very appropriate, and we can actually protect the infant from HIV infection,” said Dr. Lawrence, clinical professor of pediatrics at UFHealth, University of Florida.

Studies have shown that the postnatal transmission rate can be very low when mothers receive highly active antiretroviral therapy for the duration of breastfeeding and one month beyond.

Furthermore, research shows breastfeeding can reduce the risk of gastrointestinal infections, otitis media, lower respiratory tract infections and sudden infant death syndrome in the first year of life, with the greatest impact being seen in developing countries. Benefits extend to mothers, who have a decreased risk of developing breast and ovarian cancers.

“So, then the question is if we can keep the risk very very low, what are the benefits of breastfeeding to the mother and infant?” Dr. Lawrence said. “Or we could phrase it differently: What are the risks of not breastfeeding?”

Dr. Chadwick, however, said any risk of transmission — even 1% — is a concern.

“It’s a very realistic debate because we have done so well in reducing transmission that mothers would like to have the opportunity to breastfeed, which is perfectly understandable and laudable. The concern is that even in the studies that have looked carefully at how to prevent breastfeeding transmission, some transmissions have taken place,” said Dr. Chadwick, professor of pediatrics, Northwestern University Feinberg School of Medicine, and co-director, Section of Pediatric, Adolescent and Maternal HIV Infection, Lurie Children’s Hospital of Chicago.

A 1% risk sounds low, and the odds are definitely in a mother’s favor, she added. “But if it happens, to have something that was completely preventable is tragic.”

Despite their differences, both agree that mothers should be counseled on the risks and benefits, so they can make their own decision.

“I am an advocate for breastfeeding and would like every woman to at least have the opportunity for an informed choice in terms of how they might feed their infant,” Dr. Lawrence said.

Added Dr. Chadwick: “This needs to be an open conversation between the pediatrician and the mother, so it is not just a question of our saying, ‘The guidelines say this, so do this.’ It has to be a discussion that the mother really understands what went into the guidelines to help her feel more comfortable with whatever decision she makes.”

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