Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children

Impact of antenatal antiretroviral drug exposure on the growth of children who are HIV-exposed uninfected: the national South African Prevention of Mother to Child Evaluation cohort study

BACKGROUND

The relationship between in-utero antiretroviral (ARV) drug exposure and child growth needs further study as current data provide mixed messages. We compared postnatal growth in the first 18-months of life between children who are HIV-exposed uninfected (CHEU) with fetal exposure to ARV drugs (prophylaxis or triple-drug therapy (ART)) and CHEU not exposed to ARVs. We also examined other independent predictors of postnatal growth.

METHODS

We analysed data from a national prospective cohort study of 2526 CHEU enrolled at 6-weeks and followed up 3-monthly till 18-months postpartum, between October 2012 and September 2014. Infant anthropometry was measured, and weight-for-age (WAZ) and length-for-age (LAZ) Z-scores calculated. Generalized estimation equation models were used to compare Z-scores between groups.

RESULTS

Among 2526 CHEU, 617 (24.4%) were exposed to ART since -pregnancy (pre-conception ART), 782 (31.0%) to ART commencing post-conception, 879 (34.8%) to maternal ARV prophylaxis (Azidothymidine (AZT)), and 248 (9.8%) had no ARV exposure. In unadjusted analyses, preterm birth rates were higher among CHEU with no ARV exposure than in other groups. Adjusting for infant age, the mean WAZ profile was lower among CHEU exposed to pre-conception ART [-0.13 (95% confidence interval - 0.26; - 0.01)] than the referent AZT prophylaxis group; no differences in mean WAZ profiles were observed for the post-conception ART (- 0.05 (- 0.16; 0.07)), None (- 0.05 (- 0.26; 0.16)) and newly-infected (- 0.18 (- 0.48; 0.13)) groups. Mean LAZ profiles were similar across all groups. In multivariable analyses, mean WAZ and LAZ profiles  for the ARV exposure groups were completely aligned. Several non-ARV factors including child, maternal, and socio-demographic factors independently predicted mean WAZ. These include child male (0.45 (0.35; 0.56)) versus female, higher maternal education grade 7-12 (0.28 (0.14; 0.42) and 12 + (0.36 (0.06; 0.66)) versus ≤ grade7, employment (0.16 (0.04; 0.28) versus unemployment, and household food security (0.17 (0.03; 0.31). Similar predictors were observed for mean LAZ.

CONCLUSION

Findings provide evidence for initiating all pregnant women living with HIV on ART as fetal exposure had no demonstrable adverse effects on postnatal growth. Several non-HIV-related maternal, child and socio-demographic factors were independently associated with growth, highlighting the need for multi-sectoral interventions. Longer-term monitoring of CHEU children is recommended.

Relationship between pre-pregnancy maternal body mass index and infant weight trajectories in HIV-exposed and HIV-unexposed infants

BACKGROUND

Maternal HIV and antiretroviral therapy (ART) exposure in utero may influence infant weight, but the contribution of maternal y body mass index (BMI) to early life overweight and obesity is not clear.

OBJECTIVE

To estimate associations between maternal BMI at entry to antenatal care (ANC) and infant weight through approximately 1 year of age and to evaluate whether associations were modified by maternal HIV status, maternal HIV and viral load, breastfeeding intensity through 6 months or timing of entry into ANC.

METHODS

We followed HIV-uninfected and -infected pregnant women initiating efavirenz-based ART from first antenatal visit through 12 months postpartum. Infant weight was assessed via World Health Organization BMI and weight-for-length z-scores (WLZ) at 6 weeks, 3, 6, 9 and 12 months. We used multivariable linear mixed-effects models to estimate associations between maternal BMI and infant z-scores over time.

RESULTS

In 861 HIV-uninfected infants (454 HIV-exposed; 407 HIV-unexposed), nearly 20% of infants were overweight or obese by 12 months of age, regardless of HIV exposure status. In multivariable analyses, increasing maternal BMI category was positively associated with higher infant BMIZ and WLZ scores between 6 weeks and 12 months of age and did not differ by HIV exposure status. However, HIV-exposed infants had slightly lower BMIZ and WLZ trajectories through 12 months of age, compared with HIV-unexposed infants across all maternal BMI categories. Differences in BMIZ and WLZ scores by HIV exposure were not explained by timing of entry into ANC or maternal viral load pre-ART initiation, but z-scores were slightly higher for HIV-exposed infants who were predominantly or exclusively versus partially breastfed.

CONCLUSIONS

These findings suggest maternal BMI influences early infant weight gain, regardless of infant HIV exposure status. Intervention to reduce maternal BMI may help to address growing concerns about obesity among HIV-uninfected children.

Infant feeding, growth monitoring and the double burden of malnutrition among children aged 6 months and their mothers in KwaZulu‐Natal, South Africa

South Africa has a documented high prevalence of stunting and increasing obesity in children as well as obesity in adults. The double burden of malnutrition, which can be on an individual‐, household‐ or population level, has implications for both health and the economic development of a community and country. This paper describes a large‐scale survey (N = 774) of infant feeding, growth monitoring and anthropometry among mother and child pairs aged 6 months of age in KwaZulu‐Natal (KZN), South Africa, conducted between January and August 2017. Among children, a large increase in the prevalence of stunting and obesity was seen between birth and 6 months of age increasing from 9.3% to 21.7% and 4.0% to 21.0%, respectively. 32.1% of the mothers were overweight [body mass index (BMI): 25.0–29.9] and 28.4% had obesity grade 1 (BMI: 30–<40). Although most mothers (93%; 563/605) initiated breastfeeding, the introduction of other foods started early with 17.6% (56/319) of the mothers having started giving other fluids or food to their child within the first month. At 6 months 70.6% (427/605) children were still breastfed and 23.5% were exclusively breastfed. In addition, we found that length measurements were done less frequently than weight measurements between birth and 6 months, on average 2.2 (SD: 1.3) versus 5.8 (SD: 1.5) times. Moreover, there is a need for improvement of health worker training and understanding regarding anthropometric measurements when assessing malnutrition in children in the clinics. Early detection and improved infant feeding practices are key in preventing both stunting and obesity in children.

The double burden of malnutrition is severe in KwaZulu‐Natal with high rates of maternal obesity and increasing prevalence of stunting and obesity among infants in the first 6 months of life.

Breastfeeding and complementary feeding practices are suboptimal and additional support for breastfeeding is required in the post‐natal period and in the workplace to address breastfeeding challenges.

Growth monitoring is inadequate in health facilities leading to many lost opportunities for early identification of malnutrition. Hence, anthropometric practices and interpretation of findings need to be strengthened.

Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? - A systematic scoping review

INTRODUCTION

Suboptimal breastfeeding rates in South Africa have been attributed to the relatively easy access that women and families have had to infant formula, in part as a result of programs to prevent maternal-to-child transmission (MTCT) of HIV. This policy may have had an undesirable spill-over effect on HIV-negative women as well. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the WHO HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa.

METHODS

We applied the Joanna Briggs Institute guidelines for scoping reviews and reported our work in compliance with the PRISMA Extension (PRISMA-ScR). Twelve databases and platforms were searched. We included all study designs (no language restrictions) from South Africa published between 2006 and 2020. Eligible participants were women in South Africa who delivered a healthy live newborn who was between birth and 24 months of age at the time of study, and with known infant feeding practices.

RESULTS

A total of 5431 citations were retrieved. Duplicates were removed in EndNote and by Covidence. Of the 1588 unique records processed in Covidence, 179 records met the criteria for full-text screening and 83 were included in the review. It was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1-3 months). EBF rates rapidly declined after birth. School and work commitments were also reasons for discontinuation of EBF. HIV-positive women expressed fear of HIV MTCT transmission as a reason for not breastfeeding.

CONCLUSION

The Review found that while enforcing the most recent WHO HIV infant feeding guidelines and the WHO Code may be necessary to improve breastfeeding outcomes in South Africa, they may not be sufficient because there are additional barriers that impact breastfeeding outcomes. Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to improve breastfeeding outcomes in South Africa.

Breastfeeding, HIV exposure, childhood obesity, and prehypertension: A South African cohort study

BACKGROUND

Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent.

METHODS AND FINDINGS

The Siyakhula cohort (2012-2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother's age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21-0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26-0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38-1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47-10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65-7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall.

CONCLUSIONS

To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women.

Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now?

Background

Increasing the rate of exclusive breastfeeding (EBF) to 50% in the first six months of life is one of six major global targets set by the United Nations Decade of Nutrition, and is essential to achieve the sustainable development goals to eradicate hunger and end malnutrition by 2030.

Methods

A survey using multistage random sampling design included 99 primary health care (PHC) clinics in all 11 districts in KwaZulu-Natal (KZN). All mothers and caregivers of infants 14 weeks of age attending the clinics in the study period were requested to participate in a structured interview to explore feeding practices since birth. As non-maternal caregivers may not have detailed knowledge of feeding practices, they provided limited information about current feeding practices. Respondents who consistently reported giving no other food or fluids except breastmilk since birth were classified as practising exclusive breastfeeding (EBF), and those who were currently breastfeeding but had given other food or fluids since birth were categorised as practising mixed breastfeeding (MBF).

Results

A total of 4172 interviews were conducted with mothers and caregivers of 14 week old infants. Among mothers 49.8% were EBF, 23.1% were MBF and 27.0% were not breastfeeding. Among non-maternal caregivers 11.8% reported EBF, 23.4% MBF and 62.3% were not giving breastmilk. Higher education (OR 0.6, 95% CI 0.4–0.8) and being in the highest socio-economic tertile (OR 0.7, 95% CI 0.6–0.9) were risk factors for not practising EBF, while returning to work (OR 0.3, 95% CI 0.2–0.3) or school (OR 0.2 95% CI, 0.1–0.3) was associated with less EBF. HIV-positive mothers were more likely to have never started breastfeeding (OR 3.6, 95% CI 2.7–4.8). However, they were similar in having stopped breastfeeding by 14 weeks (OR 1.1, 95% CI 0.9–1.4) compared to HIV-negative mothers, and, they had similar rates of EBF at 14 weeks of age (OR 1.0, 95% CI 0.9–1.3).

Conclusions

Estimates of breastfeeding practices at 14 weeks in KZN are higher than previously shown. However, particular challenges that should be addressed if international targets for EBF are to be achieved include improving breastfeeding practices of HIV positive mothers and supporting all mothers, particularly working or schooling mothers to continue giving breastmilk while they are away from their children.

Predicting Undernutrition at Age 2 Years with Early Attained Weight and Length Compared with Weight and Length Velocity

OBJECTIVE

To estimate the abilities of weight and length velocities vs attained growth measures to predict stunting, wasting, and underweight at age 2 years.

STUDY DESIGN

We analyzed data from a community-based cohort study (The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development study [MAL-ED] study) in Bhaktapur, Nepal. A total of 240 randomly selected children were enrolled at birth and followed up monthly up to age 24 months. Linear and logistic regression models were used to predict malnutrition at 2 years of age with growth velocity z scores at 0-3, 0-6, 3-6, 6-9, 6-12, and 9-12 months (using the World Health Organization Growth Standards) or attained growth at 0, 3, 6, and 12 months as predictors.

RESULTS

At age 2 years, 4% of the children were wasted, 13% underweight, and 21% stunted. Children who were malnourished at age 2 years had lower mean growth z scores already at birth and throughout the study period. Anthropometric indicators in infancy were significant predictors for growth at the age of 2 years during most periods and at most ages in infancy. Weight-for-age z score, length-for-age z score, and weight-for-length z score at age 12 months had excellent areas under the curve (91-95) to predict the value of the same indicator at age 24 months. Maximum area under the curve values for weight and length velocity were somewhat lower (70-84).

CONCLUSIONS

Growth measured at one time point in infancy was better correlated with undernutrition at age 2 years than growth velocity.