Diarrhea in Uninfected Infants of HIV-infected Mothers Who Stop Breastfeeding at 6 Months: The BAN Study Experience
Athena Kourtis*1, D Fitzgerald2, L Hyde3, H C Tien2, C Chavula3, N Mumba3, M Magawa3, R Knight2, C Chasela3, C van der Horst2, and the BAN Study Team
1Natl Ctr for Chronic Disease Prevention and Hlth Promotion, CDC, Atlanta, GA, US; 2Univ of North Carolina at Chapel Hill, US; and 3Univ of North Carolina Project, Lilongwe, Malawi
Background: Recent evidence from clinical trials in Africa suggests high morbidity from diarrhea among
infants who are weaned at 6 months of life. We describe diarrhea among
uninfected infants of HIV-infected mothers enrolled in the Breastfeeding Antiretrovirals Nutrition (BAN) Study currently ongoing in Lilongwe, Malawi.
Methods: BAN is a randomized, controlled clinical trial
of an ART and a nutritional intervention among breastfeeding HIV-infected
mothers with CD4+ cell counts >200/mm3 and their
infants. Mothers are counselled to exclusively breastfeed followed by rapid
weaning by 28 weeks. Mothers and infants are randomized to a maternal or an
infant ART regimen or to standard of care during breastfeeding. In addition,
mothers are randomized to receive or not a nutritional supplement during
breastfeeding. We examined the rates of infant diarrhea and of hospitalization and death due to diarrhea in HIV-uninfected infants enrolled in the BAN
trial to-date. We compared these rates with national Malawi data in infants who follow
local feeding practices of extended breastfeeding into the second year of life.
Results: Between April 2004 and June 2006, 771
HIV-uninfected infants had been enrolled in BAN, of whom 225 uninfected infants
had reached 28 weeks of age. Figure1 shows the proportion of infants with diarrhea during the first year of life. There was an
increase around the time of weaning that continued through the end of the first
year of life. Hospitalizations due to diarrhea also
peaked around the time of weaning (Figure 2). The frequency of diarrhea was consistent with rates published in the
literature. There was a higher probability of infant diarrhea
in the rainy, compared with the non-rainy season (p <0.001). The overall HIV-uninfected infant mortality (43/1000)
was much lower than that reported in the Malawi Demographic and Health Survey
(76/1000 live births).
Conclusions: We observed an increase in diarrhea
during and following weaning among exclusively breastfed infants reportedly
weaned at 6 months. This is consistent with the pattern seen in populations who
practice prolonged breastfeeding, as this time coincides with the introduction
of complementary infant foods. Greater emphasis should be placed on hygienic
preparation of weaning foods and water purification in order to decrease infant
diarrheal morbidity in resource-limited settings.