Seattle's Child

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AAP shifts stance on HIV and breastfeeding

Local pediatrician explains the pediatric doctors group's new advice

The American Academy of Pediatrics has significantly shifted its stance on breastfeeding for mothers with or at risk of HIV, the human immunodeficiency virus. A new clinical report recently issued by AAP says mothers with HIV can breastfeed their babies with “very low” risk if they are undergoing antiretroviral treatment (ART) and maintain an undetectable viral load. 

The report, published in the journal Pediatrics, reiterates that the only sure way to avoid passing HIV to an infant is not to nurse. However, it advises pediatricians to support and guide mothers undergoing ART who show undetectable viral load if they choose to breastfeed. That’s a big change from AAP’s previous position, which advised against breastfeeding for HIV-positive mothers no matter their viral load status or ART regimen.

Know the risks and be ready to support

The report calls on pediatricians and other healthcare professionals to know the HIV transmission risks from breastfeeding and the guidelines for feeding infants with perinatal HIV exposure in the United States. 

“Pediatric health care professionals should be prepared to provide infant feeding counseling and a family-centered, culturally sensitive, harm reduction approach for people with HIV on ART with sustained viral suppression who desire to breastfeed,” the authors stated.

Breastfeeding HIV positive

Elizabeth Meade, MD, FAAP practices at Swedish Medical Center.

We asked Dr. Elizabeth Meade, director of the inpatient pediatrics resident rotation at Swedish Medical Center, about the new report. Meade is also a lactation consultant, chairs the hospital’s Pediatric Acute Care Quality and Safety Committee, and serves as the director of medical communications for the Swedish system. 

Seattle’s Child (SC): What was the recommendation previously, and what does this study tell us to change that recommendation?

Elizabeth Meade, MD, FAAP: Since 1985, the CDC, AAP, and other medical organizations have recommended that people with HIV not breastfeed their infants due to the potential risk of transmission, as long as they have a safe alternative like formula or pasteurized donor human milk. In places in the world where access to safe water, formula, and treatment for infections is more challenging, the recommendation has long been that infants born to mothers with HIV do breastfeed because of all the benefits that breastfeeding confers—optimal nutrition, lower risk of respiratory and gastrointestinal infections, etc. In the US, it was previously believed that the small but present risk of HIV transmission with breastfeeding outweighed the benefits, but given new data, that (belief) has now changed. We now have more early access to antiretroviral treatment, more effective ART, and a better understanding of the actual risk of transmission from a person with an undetectable viral load, which is close to zero. All of these pieces of information, plus even more information on the potential benefits of breastmilk, have led to an update in recommendations.

SC: How many mother-baby diads does this impact in Washington each year?

Meade: Around 50-100 babies are born to mothers with HIV in Washington each year, and around 5,000 in the United States.

SC: What are the caveats? When should a mother with HIV not nurse her infant under the new recommendations? 

Meade: To safely recommend breastfeeding for a parent with HIV, that person must be on ART (ideally before pregnancy or early in pregnancy), have sustained viral suppression (<50 copies/mL), and have continuous access to their ART medications. 

We would not recommend breastfeeding if a parent is not on ART or does not consistently have access to it, does not have a suppressed viral load, or has a new HIV diagnosis during the pregnancy or breastfeeding period. Parents may want to talk with their child’s health care provider to discuss the risks and benefits of breastfeeding if they have cracked or bleeding nipples, mastitis, or if the baby has oral thrush (yeast) infection, as these could potentially increase the risk of transmission.

SC: What other precautions should HIV-positive mothers take?

Meade: Other recommendations help us ensure the best chance of non-transmission, such as exclusive breastfeeding if possible. Studies have shown that there is a higher risk of transmission if a baby receives both breastmilk and formula or breastmilk and other foods before the age of 6 months. Regular checks of the parent’s viral load every one to two months during breastfeeding, infant antiretroviral prophylaxis medication, and gradual weaning when the parent is ready over 2 to 4 weeks instead of abruptly stopping breastfeeding [are also recommended].

SC: Low risk is not no risk. What are the statistical chances of transmission?

Meade: The risk is very small—less than 1%. However, there have been case reports of infants who acquired HIV and were breastfeeding even when the parent did not have a detectable viral load. So, the risk is not zero, but it is quite small.

While these new recommendations give us a lot more options and information to fully counsel parents on risks versus benefits, it’s an important part of the discussion to include the information that the only way to eliminate the risk of transmission via human milk completely is not to breastfeed. For some parents, that will be reason enough not to breastfeed, and for many parents, it will not—that’s part of the nuance of shared decision-making between parents and the medical team.

SC: Why is this new recommendation important to babies and mothers?

Meade: Breastfeeding comes with so many wonderful benefits—optimal nutrition, decreased risk of infections and certain chronic diseases, decreased risk of SIDS, antibodies that help protect infants from circulating germs, and decreased risk of type 2 diabetes, high blood pressure, and certain cancers in the breastfeeding parent. It can also be a wonderful part of the bonding experience and something highly important to many parents. 

As a pediatrician, mom, and lactation consultant, I know that breastfeeding is really a struggle for many people. It’s important to acknowledge that there are many safe and healthy ways to feed a baby and that there is no decrease in bonding, love, or closeness of relationship for parents who can’t or choose not to breastfeed.

SC: Is there anything else you’d like to add?

Meade: The decision to breastfeed or not for a parent who has HIV is a weighty one and can feel very complicated. Pregnant people with HIV should talk with their care teams early and often about their feeding plans and ensure that they have input from a Pediatric Infectious Disease/HIV expert who can answer questions and help with decision-making.

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About the Author

Cheryl Murfin

Cheryl Murfin is managing editor at Seattle's Child. She is also a certified doula, lactation educator for NestingInstinctsSeattle.com and a certified AWA writing workshop facilitator at Compasswriters.com.