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Growth faltering due to breastfeeding cessation in uninfected children born to HIV-infected mothers in Zambia^1,2,3

¹ From the Columbia University Gertrude H Sergievsky Center, College of Physicians and Surgeons and Mailman School of Public Health, New York, NY (SA, AF, and LK); the Childrens Hospital, Los Angeles, CA (GMA); the University Teaching Hospital, Lusaka, Zambia (CK and MM); the Lusaka District Health Management Team, Lusaka, Zambia (MS); and Boston University School of Public Health, Boston, MA (DMT).

² Supported by the National Institute of Child Health and Human Development (HD 57161, HD 39611, and HD 40777). GMA is a recipient of the Elizabeth Glaser Pediatric AIDS Foundation Scientist Award.

³ Address correspondence to S Arpadi, Gertrude H Sergievsky Center, College of Physicians and Surgeons, Columbia University Medical Center, 630 West 168th Street, New York, NY 10030. E-mail: sma2{at}columbia.edu.

Background: The effect of breastfeeding on growth in HIV-exposed infants is not well described.

Objective: The objective was to evaluate the effect of early breastfeeding cessation on growth.

Design: In a trial conducted in Lusaka, Zambia, HIV-infected mothers were randomly assigned to exclusive breastfeeding for 4 mo followed by rapid weaning to replacement foods or exclusive breastfeeding for 6 mo followed by introduction of complementary foods and continued breastfeeding for a duration of the mother's choice. Weight-for-age z score (WAZ), length-for-age z score (LAZ), and weight-for-length z score (WLZ) and the self-reported breastfeeding practices of 593 HIV-uninfected singletons were analyzed. Generalized estimating equations were used to adjust for confounders.

Results: WAZ scores declined precipitously between 4.5 and 15 mo. The decline was slower in the breastfed infants. At 9, 12, and 15 mo, mean WAZs were, respectively, –0.74, –0.92, and –1.06 in infants who were reportedly breastfed and were –1.07, –1.20, and –1.31 in the weaned infants (P = 0.003, 0.007, and 0.02, respectively). No differences were observed past 15 mo. Breastfeeding practice was not associated with LAZ, which declined from –0.98 to –2.24 from 1 to 24 mo. After adjustment for birth weight, maternal viral load, body mass index, education, season, and marital and socioeconomic status, not breastfeeding was associated with a 0.28 decline in WAZ between 4.5 and 15 mo (P < 0.0001). During the rainy season, not breastfeeding was associated with a larger WAZ decline (0.33) than during the dry season (0.22; P for interaction = 0.02).

Conclusions: Early growth is compromised in uninfected children born to HIV-infected Zambian mothers. Continued breastfeeding partially mitigates this effect through 15 mo. Nutritional interventions to complement breastfeeding after 6 mo are urgently needed. This trial was registered at clinicaltrials.gov as NCT00310726.