Transition to Replacement Feeding by HIV-Positive Women Who Breastfeed
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on Replacement Feeding:
Transition to Replacement Feeding by
HIV-Positive Women Who Breastfeed
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A series of updates on critical infant and young child feeding issues
gaps remain in our knowledge of the risks associated with various infant
feeding strategies under different conditions. This guidance, based on the
best information currently available, is for HIV-positive women who choose
to transition from breastfeeding to replacement feeding at about 6 months.
Infant feeding options pose a dilemma for the
HIV-positive mother. Without interventions to reduce the risk of HIV
transmission through breastfeeding, approximately 10 percent to 20 percent of
infants of HIV-positive mothers would be infected this way if breastfed for
18–24 months. Choosing not to breastfeed eliminates this risk but could increase
the risk of malnutrition, diarrhea, and acute respiratory infections—major
causes of infant death.
Feeding options should be as safe as possible.
UN agencies recommend that HIV-infected women avoid breastfeeding when
replacement feeding is acceptable, feasible, affordable, sustainable, and safe.
As long as these criteria are not met, they recommend exclusive breastfeeding
“during the first months of life.”1
HIV-positive women who breastfeed can reduce the risk of transmission by
preventing and treating cracked nipples, mastitis, and breast abscess.
The appropriate time to stop breastfeeding must always
be assessed on an individual basis. The World Health Organization
recommends that an HIV-negative mother breastfeed for 2 years and beyond.
However, for the HIV-positive mother, early cessation of breastfeeding shortens
the duration of an infant’s exposure to HIV. The age at which replacement
feeding becomes acceptable, feasible, affordable, sustainable, and safe is
imprecise and depends on the environment and socioeconomic conditions in the
Under conditions common in resource-limited settings,
many experts recommend a transition from exclusive breastfeeding to replacement
feeding at or before 6 months of age. After the first few months of
infancy, the risks to infant survival associated with the use of breastmilk
substitutes, such as infant formula and animal milk, are reduced. At about 6
months the infant is also better able to tolerate undiluted2 animal milk and a variety of semi-solid foods, so
the options for replacement feeding become safer, less difficult, and less
expensive than replacement feeding at an earlier age.
Definition of Terms
Breastmilk substitute: any food
marketed or used as a partial or total replacement for breastmilk, whether
or not suitable for that purpose
Exclusive breastfeeding: giving an
infant only breastmilk and no other solids or liquids, not even water
Replacement feeding: giving an infant
who is not receiving any breastmilk a nutritionally adequate diet until the
age at which the child can be fully fed on family foods
Transition: a period and process to
accustom the infant and mother to new feeding patterns, after which all
breastmilk is replaced with breastmilk substitutes
Transitioning to replacement feeding at about 6 months
A woman who chooses to transition to replacement feeding at about six months
can minimize her discomfort and allow time for the infant to adjust to the new
feeding patterns over a period of 2–3 days to 2–3 weeks. An open cup, rather
than a bottle, should be used for transitional and replacement feeding. Bottles
and nipples are difficult to clean and are often contaminated.
To aid in the transition from breastfeeding to
replacement feeding, the mother can:
- Accustom the infant to cup feeding by introducing expressed
breastmilk by cup. One strategy is to offer expressed breastmilk by cup
between regular breastfeeds. This will help the baby get used to cup feeding.
- Eliminate one feeding at the breast at a time once the infant
accepts cup feeding and replace with expressed breastmilk given by cup.
- Express breastmilk and discard it if the breasts become engorged
during this process. Use cold compresses to reduce the inflammation due to
- Avoid reinitiating breastfeeding after completing the transition to
replacement feeding. Resist the desire to breastfeed at nighttime or when
the child wants comforting.
Feeding infants 6–8 months of age
If breastfeeding is stopped at around 6 months, parents need to know how to
prepare adequate and appropriate breastmilk substitutes and semi-solid foods to
ensure the infant’s health, growth, and development.
Appropriate breastmilk substitutes
Milk products are good sources of energy and other nutrients for the
non-breastfed child. Milks appropriate for infants 6–8 months old include:
- Commercial infant formula: Follow directions on the tin and safety
guidelines (see box)
- Fresh animal milk: Bring to a boil to kill any germs
Powdered full-cream milk or evaporated milk: Add boiled water to make
the equivalent amount of fresh cow’s milk, as instructed on the package or tin
Processed/pasteurized or ultra-high temperature (UHT) milk: No
Sweetened condensed milk and skimmed milk should not be used as
breastmilk substitutes. They are nutritionally inferior to other types of milk.
Breastmilk substitutes should be fed by cup. If refrigeration is not available,
any milk left in the cup after the feed should be thrown away, used in cooking,
or consumed by another family member.
Infants with diarrhea should continue to receive milk along with extra liquids
and other foods to prevent dehydration and weight loss.
Feeding powdered infant formula or powdered milk
- Water that has been boiled vigorously for a few seconds and
- Adequate supplies of fuel to boil the water
- Utensils to prepare and feed the formula (pan, cups, measures
for water and milk, spoon, tongs to remove utensils from hot water) and
adequate quantities of water and soap to clean the utensils
- Good hygiene, proper sanitation, and a clean surface to prepare
- Careful preparation to avoid a mixture that is too concentrated
or too diluted
- Time to prepare feeds several times a day if refrigeration is
Introduction of soft, appropriate foods
At 6 months an infant needs more than milk to satisfy nutrient needs. At this
age the infant is developmentally ready for soft and semi-solid foods. These
foods should be adequate in quantity and quality, safely prepared, and properly
Quantity and frequency: At 6 months infants
can eat pureed, mashed, and semi-solid foods. By 8 months they can feed
themselves cut-up fruit and vegetables. The amount of food and the number of
feedings will increase as the child gets older. Infants 6–8 months old should
receive 2–3 feedings of complementary food, with nutritious snacks offered 1–2
times per day, as desired. The appropriate number of feeds depends on the energy
density of the local foods and the usual amounts consumed at each feed.
Quality: Infants should eat a variety of
nutrient-rich foods, including animal products, fruits, and vegetables. Iron
supplements should be given daily to non-breastfed infants according to national
protocols if a daily vitamin-mineral supplement, iron-fortified food, or
iron-fortified commercial formula is not available. In vitamin A deficient
areas, infants should receive a semi-annual, high-dose vitamin A supplement
starting at 6 months.
Hygiene: Handwashing, clean utensils, and
safe food preparation and storage can prevent the introduction of dirt and germs
that might cause diarrhea and other infections. Liquids such as juices should be
fed from a small cup or bowl, not a bottle.
Detailed guidelines on breastfeeding, breastmilk expression, preparation of
breastmilk substitutes, and complementary feeding are available in LINKAGES’
Infant Feeding Options in the Context of HIV, found at http://www.linkagesproject.org/
1 WHO. HIV and infant feeding: framework
for priority action. Geneva: World Health Organization, 2003.
2 Animal milks given to infants less than
six months need to be modified by adding boiled water, sugar, and
3 Instead of replacement feeding, a
mother may choose to feed the infant her heat-treated, expressed breastmilk or
have a wet nurse feed the child. Wet nursing should only be considered if the
wet nurse is offered HIV counseling and testing, voluntarily takes a test, tests
HIV negative, and practices safe sex. A small chance exists that an HIV-positive
infant could pass the virus to a wet nurse if the infant had a sore in the mouth
or the wet nurse had a breast condition such as cracked nipples.
Spotlight: Replacement Feeding: Transition to Replacement Feeding by
HIV-Positive Women Who Breastfeed is a publication by LINKAGES: Breastfeeding,
LAM, Related Complementary Feeding, and Maternal Nutrition Program, and was made
possible through support provided to the Academy for Educational Development
(AED) by the Bureau for Global Health of the United States Agency for
International Development (USAID), under the terms of Cooperative Agreement No.
HRN-A-00-97-00007-00. The opinions expressed herein are those of the author(s)
and do not necessarily reflect the views of USAID or AED.
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