The 27th Special Session of the General Assembly on Children
(UNGASS)

Following are the notes from attendance at these sessions:

Infant Feeding in Resource-Poor Countries in the Face of HIV/AIDS
Panel Chair: Dr Miriam Labbok

Opening remarks:
Dr Labbok stated that of the 580,000 deaths from HIV/AIDS in children under 15 years of age, 500, 000 have been in Africa. She stated that 80-90% of these were due to mother-to-child transmission (MTCT), and estimated that 200,000 were secondary to breastfeeding. She went on to state that breastfeeding, overall, has saved 5 million lives in the same time period. There has been an 8% increase in the last 10 years in exclusive breastfeeding. This has saved an extra $2 million on buying formula, and has delayed 6 million births. Miriam stated that UNICEF's current policy is that women who are not HIV-infected, or do not know their HIV status, should exclusively breastfeed. In communities where it is acceptable, feasible, affordable, sustainable and safe, they are recommending to avoid breastfeeding.

"Optimal feeding beyond six months", Dr Isaac Akinyele, Nigeria, Nutrition expert:
Dr Akinyele recommended breastfeeding for 6 months, and then replacement feeding. Adding high-selenium complementary foods may help to decrease virus transmission. He also suggested that after 6 months mothers can use cow's milk if pasteurized. He mentioned that some people add crayfish, palm oils, and periwinkles. He stated that one problem with a very poorly diversified diet is that micronutrient needs for Ca, Fe, Vit. A and Zn are not met. He remarked that the ability to use local foods is important, and mentioned a technique called Co-fermentation of complementary foods by the mother, mixing local foods and natural microorganisms in a bowl for 36 hours, adding legumes, etc and then grinding them for the baby (6 months or older). He stated that this strategy increases nutritional value, and increases digestibility by breaking down some starches, decreases viscosity (important in the 6-9 month semi-solid stage).

"Infant feeding, infant survival, and mother-to-child transmission of HIV - report from a four-country study", Dr Michael Latham, Cornell University, Nutrition expert:
Dr Latham stated that there have been studies that have found HIV in breast milk. However, decisions need to be made based on risk assessment, as with other diseases. In the case of infant feeding, all options have risks.

Risk of transmission :

In Namibia, breastfeeding is still the norm, but in Botswana women were moving away from breastfeeding. All countries have a high prevalence of HIV, all are breastfeeding cultures, all have very different policies in regard to MTCT/infant feeding and HIV. There has been a major decline in breastfeeding in all these countries in recent years, with low exclusive breastfeeding rates. There have been declines in BFHI initiatives, and declines in support of the Code. He went on to say that there is a widely held myth by health workers that all mothers who are HIV+ will transmit HIV to their infants, and so therefore they do not discuss the dangers of not breastfeeding. He talked about the Coutsoudis study, which showed that there is no significant difference in transmission between exclusive formula feeding and exclusive breastfeeding.

"Socio-cultural determinants of feeding choices - Africa", Chloe O'Gara, Ready to Learn:
Ms. O'Gara mentioned the Vitamin A study in Zimbabwe, in 1999-2000: of 221 women who received their HIV results and intensive counseling, 29% were +, and 95% of those chose to breastfeed. Most people do not want to know their status, even if they can be tested. She stated that 99 % of HIV+ women breastfeed

Lessons learned from this close observation were:

"Socio-cultural determinants of feeding choices - Brazil", Dr Marina Rea, Sao Paolo, Consultant to the Minister of Health, Member/founder IBFAN:
Dr Rea began by stating that in Brazil, ARVs are provided to everyone free of charge. They use generic drugs and have agreements with pharmaceutical companies. Dr Rea stated that the median duration of exclusive breastfeeding in Sao Paulo, Brazil according to a 1999 survey is 9 days. Brazil has a huge human milk network. The milk is pasteurized before it is given out. Brazil has made human milk affordable. 71% of HIV+ women in Brasilia get banked milk for their infants. Dr Rea stated that with pasteurization, milk is heated to 62.5 degrees for 30 minutes, and this inactivates the virus. In the year 2000, Brazil collected over 79,000 liters of breastmilk.

"Socio-cultural determinants of feeding choices- India", Dr Subha Raghavan, Columbia University:
What this study found was that mothers decided to do what the healthcare provider said to do and the healthcare workers were biased themselves. Dr Raghavan noted there is a very high morbidity/mortality rate among replacement fed babies. Due to this there is a new national policy: during the first four months, babies should be exclusively breastfed with gradual weaning at 4-6 months of age. The challenge is now to disseminate this policy to the healthcare workers.

"Infant feeding in Resource-Poor Countries in the Face of HIV/AIDS : Lessons Learnt", Dr Arun Gupta, Breastfeeding Promotion Network Of India:
Dr. Gupta remarked that a major problem is that counselors do not understand what "exclusive breastfeeding" means and they believe that artificial feeding is safe. Physicians have heard that there is viral transmission during breastfeeding, therefore it is essential to train counselors with the most up-to-date breastfeeding. His papers brought out clearly the risks associated with not breastfeeding and called for ongoing and better research into the impact of different feeding methods. He recommended working to decrease mixed feeding as a way to increase exclusive breastfeeding as well as to protect the child.

"How to make breastmilk and breastfeeding safer", Helen Armstrong:
She stated that in the US there is a stigma against breastfeeding while HIV+, and babies can be removed from their moms who are breastfeeding them, while in many other parts of the world, not breastfeeding leads to stigmatization. She notes that poor nutritional status accelerates disease. In a Latin American study partial breastfeeding was linked to a 4-fold increase in mortality, doubling the rates of diarrhea and respiratory pneumonias, and no breastfeeding was linked to a 15-fold increase in mortality, with rates of diarrhea and respiratory pneumonia's quadrupling. Dr Armstrong commented that even when HIV+ women do NOT breastfeed, we see increased transmission in the first six weeks postpartum. She also noted that between 1986 and the present, the exclusive breastfeeding rate in Brazil increased from 4 to 40%. On the topic of safer breastfeeding practices, Dr Armstrong spoke about the Coutsoudis study, stating that mixed feeding has a higher rate of transmission. She then went on to discuss a strategy for rapid cessation of breastfeeding, clarifying that "the bottom line is that we don't know if this is necessary" but that it can reduce subclinical mastitis in the mom, which might increase transmission during the weaning process. Based on an idea by Gabrielle Palmer, this process has three stages: 1. mother continues to breastfeed but starts to comfort the baby by other means and includes the family more in emotional nurturing of the baby, and begins some hand expression; 2. mom expresses more, heat treats the milk and cup feeds, breastfeeding some, while continuing close comforting by mom and family; and 3. mom stops breastfeeding, expresses and heat treats the milk and comforts without nursing. Helen proposed this as a three-week process.

Improving Children's Environmental Health
Sponsored by Physicians for Social Responsibility, INCHES, UNICEF, UNEP, WHO.

"Global water challenges and private-public sector partnerships", Steve Hilton, Conrad Hilton Foundation:
Lack of access to safe drinking water affects 1/5 of the world's population. 1.1 billion still do not have clean water, 2.4 billion have inadequate sanitation. Diarrhea kills over 2 million children/year. The Hilton Foundation is working in Ghana to improve the water situation and accessibility, with the goal of decreasing diarrhea, guinea worm disease, trachoma (causes blindness-- 540 million are at risk).

Peter Van den Hazel, Dutch, founder of INCHES, spoke on children's special vulnerabilities: children have many different environments (home, school, play), immature biochemical systems, immature ability to deal with environmental exposures, more exposed unit/body weight (more inhaled air, higher metabolisms, more water intake, more food intake.)

"Environmental Threats and Children's Health", Hans Trodesson, WHO perspective:
An unfinished priority of the last century is high mortality secondary to infectious disease. There is a huge persistent problem of malnutrition. Also now emerging are epidemics of non-communicable diseases and injuries. One-third of the global burden of disease is due to environmental exposures. 11 million children/yr. die - 99% in developing countries. Killers: respiratory infections, diarrhea, HIV/AIDS, and malaria. 60% of these deaths are related to malnutrition, often related to poverty, often living in poor environments. The Bangkok statement promotes protection of children's environments.