6.1.1. What to feed?

A baby's own mother's milk is best for LBW infants of all gestational ages. Breast milk is especially adapted to the nutritional needs of LBW infants, and strong and consistent evidence (1) shows that feeding mother's own milk is associated with lower incidence of infections and better long-term outcomes.

Not all LBW infants are able to feed from the breast in the first days of life. For infants who are not able to breastfeed effectively, feeds have to be given by an alternative, oral feeding method (cup/paladai/spoon/direct expression into mouth) or by intra-gastric tube feeding (see Session 4.6).

In these situations, the options available for feeding the LBW infant are, in order of preference (1):

• expressed breast milk (EBM) (from his or her own mother);
• donor breast milk (4);
• infant formula:

  —

  standard infant formula for infants with birth weight >1500 g

  —

  pre-term formula for infants with birth weight <1500 g;

A LBW baby who is not able to breastfeed usually needs care in a special newborn care unit. Every effort should be made to enable a mother to stay in or near this unit. Otherwise, she should spend as much time there as possible every day. When breastfeeding is established, care can continue at home with close follow-up.

A baby should have as much skin-to-skin contact with his or her mother as possible, to help both bonding and breastfeeding. If a baby is too sick to move, the mother should at least be able to talk to him or her, and to have hand contact.

A mother should be given skilled help to express her milk and to establish lactation starting, if possible, within 6 hours of birth. She should express at least 8 times in 24 hours, expressing at home if she is not staying in the health facility. The EBM can be given every 1–3 hours according to the age and weight of the baby.

Supplements of vitamin D and phosphate may be recommended as soon as oral or intra-gastric feeding commences for VLBW infants, and supplements of iron are recommended for all LBW infants from the age of 6 to 8 weeks.

6.1.2. How to feed?

Babies of 36 weeks gestational age or more can often suckle well enough at the breast to feed themselves fully. Help the mother to have skin-to-skin contact with the baby, and to let the baby try to suckle as soon as possible after delivery. Show the mother how to hold the baby in the underarm position, or hold with the arm from the side opposite the breast (see Figure 16). These positions are especially useful for very small babies. Make sure that the baby is well attached at the breast. When a LBW baby first suckles, he or she may pause quite often and for long periods during a feed, and may need to continue feeding for an hour. It is important not to take the baby off the breast during these pauses.

FIGURE 16

Useful positions to hold a LBW baby for breastfeeding.

The baby should be allowed to suckle every three hours, or more frequently on demand. If a baby has difficulty suckling effectively, tires quickly at the breast or does not gain adequate weight, offer expressed milk by cup after the breastfeed, or give alternate breast and cup feeds.

Babies of 32 to 36 weeks gestational age need to be fed partly or fully on EBM by cup or spoon until full breast-feeding can be established. Feeds can start as soon as the baby is clinically stable, if possible within one hour of birth, and should be given 2–3 hourly. To stimulate breastfeeding, these babies should be allowed to suckle or lick the breast as much as they wish. Expressing some breast milk directly into the baby's mouth gives the baby the taste of milk and stimulates the sucking and swallowing reflexes (see instructions in Box 15). Thereafter, offer the full amount of feed by cup (Table 8). The baby may not finish all the cup feed as he or she may have already had some milk from the breast. Reduce the cup feeds slowly if the baby starts suckling well. Bottle feeding should be avoided, as it may interfere with the baby learning to breastfeed.

Box 15

How to express breast milk directly into a baby's mouth. Ask the mother to: Wash her hands

TABLE 8

Recommended feed volumes for LBW infants.

Babies less than 32 weeks gestational age usually need to be fed by gastric tube. They should not receive any enteral feeds in the first 12–24 hours. Table 7 shows the quantity of milk that a LBW baby fed by gastric tube needs each day and Table 8 shows how much is needed at each feed. The quantity needs to be exact. However, babies less than < 1500g may need to receive some of these requirements as intravenous fluids, as they may not tolerate full enteral feeds.

TABLE 7

Recommended fluid intake for LBW infants.

The quantities in the table are calculated according to the baby's need for:

• 60 ml/kg on day 1, increasing by 10 or 20 ml per day over 7 days up to 160 ml/kg/day.
• 8 feeds in 24 hours.

If a baby has more than 8 feeds in 24 hours, the amount per feed must be reduced accordingly, to achieve the same total volume in 24 hours.

Cup feeds

A baby who is cup fed (see Figure 17) needs to be offered 5 ml extra at each feed. This slightly larger amount allows for spillage with cup feeding. It is important to keep a record of the 24-hour total and ensure that it meets the required total ml/kg per day for the baby's weight.

FIGURE 17

Cup feeding a low-birth-weight baby.

6.1.3. Follow up of LBW babies

The baby should have follow-up visits at least once 2–5 days after discharge, and at least weekly until fully breastfeeding and weighing more than 2.5 kg. Ideally these should be home visits by a community breastfeeding counsellor, or visits by the mother to a nearby health facility. Further follow-up can then continue monthly as for a term baby.

6.1.4. Kangaroo mother care

Kangaroo mother care (KMC) is a way in which a mother can give her LBW or small baby benefits similar to those provided by an incubator (5). The mother has more involvement in the baby's care; and she has extended skin-to-skin contact, which helps both breastfeeding and bonding, probably because it stimulates the release of prolactin and oxytocin from her pituitary gland. KMC helps a mother to develop a close relationship with her baby, and increases her confidence.

Management

The mother keeps her baby in prolonged skin-to-skin contact day and night, in an upright position between her breasts (Figure 18). The baby is supported in this position by the mother's clothes, or by cloths tied around her chest. The baby's head is left free so that he or she can breathe, and the face can be seen. The baby wears a nappy for cleanliness and a cap to keep the head warm.

FIGURE 18

Baby in Kangaroo mother care position.

KMC has been shown to keep the baby warm, to stabilize his or her breathing and heart rate, and to reduce the risk of infection. It helps the mother to initiate breastfeeding earlier, and the baby to gain weight faster. Most routine care can be carried out while the baby remains in skin-to-skin contact. When the mother has to attend to her own needs, skin-to-skin contact can be continued by someone else, for example by the father or a grandparent, or the baby can be wrapped and put into a cot or on a bed until KMC can be continued.

It is not essential for a baby to be able to coordinate sucking and swallowing to be eligible for KMC. Other methods of feeding can be used until the baby is able to breastfeed. Close contact with the mother means that the baby is kept very near to her breasts, and can easily smell and lick milk expressed onto her nipple. He or she can be given breast milk by direct expression into his mouth until able to attach well.

KMC should be continued for as long as necessary, which is usually until the baby is able to maintain his or her temperature, is breathing without difficulty and can breastfeed without the need for alternative methods of feeding. It is usually the baby who indicates that he or she is ready and ‘wants to get out’. If the mother lives near the hospital or health facility the baby may be discharged breastfeeding and/or using an alternative feeding method, such as cup feeding with the mother's EBM.

The mother and her baby should be monitored regularly. In the first week after discharge, the baby should be weighed daily, if possible, and a health care worker should discuss any difficulties with the mother, providing her with support and encouragement. Monitoring should continue until the baby weighs more than 2.5 kg. When the baby becomes less tolerant of the position, the mother may reduce the time in KMC and then stop altogether over about a week. Once the baby has stopped KMC, monthly follow-up should be continued to monitor feeding, growth and development until the baby is several months old.

Why infant and young child feeding is exceptionally vulnerable in emergencies

In emergencies infants and young children are more likely than older children or adults to become ill and die from malnutrition and disease (10). Optimal feeding is often disrupted because of lack of basic resources such as shelter and water, and physical and mental stress on families. Breastfeeding may stop because mothers are ill, traumatised, or separated from their babies, and yet it is particularly valuable in emergency situations (11). Artificial feeding is more dangerous because of poor hygiene, lack of clean water and fuel, and unreliability of supplies. There may be no food suitable for complementary feeding, or facilities for preparing feeds and storing food safely.

Breast-milk substitutes including infant formula and feeding bottles may be sent to emergency situations in inappropriate amounts by donors who believe that they are urgently required, but who are poorly informed about the real needs. Without proper controls, these supplies are often given freely to families who do not need them, and stocks run out before more arrive for those who might have a genuine need (12). The result is inappropriate and unsafe use of breast-milk substitutes, and a dangerous and unnecessary increase in early cessation of breastfeeding. Babies may be given unsuitable foods, such as dried skimmed milk, because nothing else is available.

Management in emergencies

The principles and recommendations for feeding infants and young children in emergency situations are exactly the same as for infants in ordinary circumstances. For the majority, the emphasis should be on protecting, promoting and supporting breastfeeding, and ensuring timely, safe and appropriate complementary feeding. Most malnourished mothers can continue to breastfeed while they are being fed and treated themselves. A minority of infants will need to be fed on breast-milk substitutes, short term or long term. This may be necessary if their mothers are dead or absent, or too ill or traumatised to breastfeed, and no wet-nurses are available; or for infants who have been artificially fed prior to the emergency or whose HIV-positive mothers choose not to breastfeed.

Supportive general conditions

A number of general conditions can greatly benefit infant and young child feeding, and staff who are managing an emergency response should endeavour to establish them:

Recognition of vulnerable groups: Pregnant women, infants under 6 months, and young children between 6 and 24 months should be counted and registered separately. Newborn infants should be registered immediately, and the household made eligible for an additional ration for the breastfeeding mother and food suitable for complementary feeding of young children, when appropriate.

Adequate food, water and nutrients: Mothers should receive an adequate general ration, and sufficient drinking water. If the full general ration is not available, food and micronutrient supplements should be provided as a priority for pregnant and lactating women.

Shelter and privacy: Shelters for families should be provided in preference to communal shelters. Breastfeeding women need private areas (as culturally appropriate) at distribution or registration points, and rest areas in transit sites.

Community support: Women need support from their family and communities, so the population should be helped to settle in familiar groups.

Reduction of demands on time: People spend hours queuing for relief commodities such as food, water, and fuel, which is difficult for mothers caring for young children. Priority access for mothers and other caregivers enables them to give children more time. Sanitary washing facilities should be set up near the area assigned to women with infants.

Specific help with feeding in emergencies

In addition to supportive general conditions, mothers need help with infant and young child feeding specifically. An emergency response should aim to include the following forms of support:

Baby-friendly maternity care: The Ten Steps for Successful Breastfeeding (see Session 4.1, Box 5) should be implemented at both health facilities and for home deliveries. Skilled support from trained breastfeeding counsellors and community groups is needed antenatally and in the first weeks after delivery.

Availability of suitable complementary foods: In addition to breast milk, infants and young children from 6 months onwards need complementary foods that are hygienically prepared and easy to eat and digest. Blended foods, especially if they are fortified with essential nutrients, can be useful for feeding older infants and young children. However, their provision should not interfere with promoting the use of local ingredients and other donated commodities for preparing suitable complementary foods (see Session 3). The use of feeding bottles should continue to be discouraged.

Skilled help in the community to:

• teach mothers how to breastfeed and continue to support them until their infant reaches 24 months;
• teach mothers about adequate complementary feeding from 6 months of age using available ingredients;
• support mothers to practise responsive feeding;
• identify and help mothers with difficulties, and follow them up at home if possible;
• monitor the growth of infants and young children, and counsel the mother accordingly.

Adequate health services to:

• support breastfeeding and complementary feeding;
• help mothers to express their milk and cup feed any infant who is too small or sick to breastfeed;
• search actively for malnourished infants and young children so that their condition can be assessed and treated;
• admit mothers of sick or malnourished infants to the health or nutrition rehabilitation clinic with their children;
• help mothers of malnourished infants to relactate and achieve adequate breastfeeding before discharge from care, in addition to necessary therapeutic feeding.

Controlled use of breast-milk substitutes (BMS): Breast-milk substitutes should be procured and distributed as part of the regular inventory of foods and medicines, in quantities only as needed (see also UNHCR policy (13)). There should be clear criteria for their use, agreed by the different agencies that are involved for each particular situation (14), but usually including the following:

• If a child's mother has died or is unavoidably absent.
• If a mother is very ill (temporary use may be all that is necessary).
• If a mother is relactating (temporary use).
• If a mother tests HIV-positive and chooses to use a breast-milk substitute (see Session 6.5).
• If a mother rejects the infant, for example after rape (temporary use may be all that is necessary).
• If an infant (born before the emergency) is already dependent on artificial feeding (use BMS to at least six months or use temporarily until relactation is achieved).

For an infant identified according to agreed criteria as in need of BMS, supplies should be provided for as long as the infant needs them. Caregivers should receive guidance about hygienic and appropriate feeding with BMS (10). Every effort should be made to prevent “spill over” of artificial feeding to mothers and babies who do not need it, by teaching the caregiver privately to prepare feeds, and by taking care not to display containers of BMS publicly.

Motivation and support

Most women can relactate any number of years after their last child, but it is easier for women who stopped breastfeeding recently, or if the infant still suckles sometimes. A woman needs to be highly motivated, and well supported by health care workers. Continuing support can be provided by community health workers, mother support groups, women friends, older women and traditional birth attendants.

Stimulation of the breasts

Stimulation of the breasts is essential, preferably by the infant suckling as often and for as long as possible. Many infants who have breastfed before are willing to suckle, even if there is not much milk being produced currently. Suckling causes release of prolactin, which stimulates growth of alveoli in the breast and the production of breast milk. The mother and infant must stay together all the time. Skin-to-skin contact, or kangaroo mother care (see Session 6.1.4) are helpful. If the infant is willing to suckle, the mother should put him or her to the breast frequently, at least 8–12 times every 24 hours, ensuring that attachment is good. If the infant is not willing to suckle, she can start the relactation process by stimulating her breasts with gentle breast massage and then with 20–30 minutes of hand expression 8–12 times a day.

Supplementary feeds for the infant

The infant needs a temporary supplement, which can be expressed milk, artificial milk or therapeutic formula. The full amount of supplement should be given initially, in a way that encourages the infant to resume breastfeeding, by cup or supplementer (see below). Avoid using feeding bottles or pacifiers. Whenever the baby wants to suckle, he or she should do so from the breast. For infants who are not willing to suckle at the breast, the supplementary suckling technique is useful.

The supplementary suckling technique

This technique usually needs to be practised under supervision at a health facility. A breastfeeding supplementer consists of a tube which leads from a cup of supplement to the breast, and which goes along the nipple and into the infant's mouth. The infant suckles and stimulates the breast at the same time drawing the supplement through the tube, and is thereby nourished and satisfied (see Figure 19). A fine nasogastric tube (gauge 8) or other fine plastic tubing should be used. The mother can control the flow by raising or lowering the cup so that the infant suckles for about 30 minutes at each feed. If the tube is wide, a knot can be tied in it, or it can be pinched. The cup and tube should be cleaned and sterilized each time she uses them.

FIGURE 19

Using supplementary suckling to help a mother to relactate.

Encourage the mother to let the infant suckle on the breast at any time that he or she is willing – not just when she is giving the supplement. When the infant is willing to suckle at the breast without the supplement, then she can start giving breast milk by cup instead. This should be more feasible in home conditions.

Quantity of supplement to give

The full amount of milk normally required by a term baby is 150 ml/kg body weight per day. To start relactation, give the full amount of supplement each day. Divide this into six to twelve feeds depending on the infant's age and condition. Young, weak or sick infants will need more frequent, smaller, feeds.

Monitor the infant's weight and urine production (see Session 7.10). When the infant is gaining weight, and there are signs of breast-milk production, the supplement can be reduced, by 50 ml per day every few days.

Signs that breast milk is being produced

Breast-milk production may start in a few days or a few weeks. Signs include:

• Breast changes: The breasts feel fuller or firmer, or milk leaks or can be expressed.
• Less supplement consumed: The infant takes less supplement while continuing to gain weight.
• Stool changes: The infant's stools become softer, more like those of a breastfed infant.

Lactogogues

Drugs (called lactogogues) are sometimes used to stimulate increased lactation, if the above measures are not effective by themselves. Drugs used are metoclopramide (given 10 mg 3 times a day for 7–14 days) or domperidone (given 20–40 mg 3 times a day for 7–10 days). However, drugs help only if the woman also receives adequate help and her breasts are fully stimulated by the infant suckling.

Follow-up

When relactation is well under way, the mother-baby pair can be discharged for daily community-level follow-up, with checks as often as possible from health and nutrition workers.

Mother-to-child transmission of HIV

In 2007, about 2.5 million children under 15 years of age were living with HIV, and an estimated 420 000 children were newly infected. The predominant source of HIV infection in young children is MTCT. The virus may be transmitted during pregnancy, labour and delivery, or during breastfeeding (15). Without intervention, an estimated 5%-20% of infants born to HIV-infected women acquire the infection through breastfeeding. Transmission can occur at any time while a child is breastfeeding, and continuing to breastfeed until the child is older increases the overall risk. Exclusive breastfeeding in the first few months of life carries a lower risk of HIV transmission than mixed feeding (16).

The main factors which increase the risk of HIV transmission through breastfeeding include (15):

• acquiring HIV infection during breastfeeding, because of high initial viral load;
• the severity of the disease (as indicated by a low CD4+ count or high RNA viral load in the mother's blood, or severe clinical symptoms);
• poor breast health (e.g. mastitis, sub-clinical mastitis, fissured nipples);
• possibly, oral infection in the infant (thrush and herpes);
• non-exclusive breastfeeding (mixed feeding);
• longer duration of breastfeeding;
• possibly, nutritional status of the mother.

Current feeding recommendations (17,18)

The United Nations recommendations for feeding of infants by mothers who are HIV- infected include:¹

• The most appropriate infant feeding option for an HIV-infected mother depends on her individual circumstances, including her health status and the local situation, but should take consideration of the health services available and the counselling and support she is likely to receive.
• Exclusive breastfeeding is recommended for HIV-infected mothers for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time (see Box 16 for definitions).
• When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended.
• All HIV-exposed infants should receive regular follow-up care and periodic re-assessment of infant feeding choices, particularly at the time of infant diagnosis and at 6 months.
• At 6 months, if adequate feeding from other sources cannot be ensured, HIV-infected women should continue to breastfeed their infants and give complementary foods in addition, and return for regular follow-up assessments. All breastfeeding should stop once an adequate diet without breast milk can be provided.
• Breastfed infants and young children who are HIV-infected should continue to breastfeed according to recommendations for the general population.

Box 16

Definitions of Acceptable, Feasible, Affordable, Sustainable and Safe. Acceptable: The mother perceives no significant barrier to choosing a feeding option for cultural or social reasons or for fear of stigma and discrimination.

Women who need anti-retroviral drugs (ARVs) for their own health should receive them, as they are the women most likely to transmit HIV through breastfeeding. Comparative studies in women who do not yet require treatment on the safety and efficacy of ARVs taken during breastfeeding solely to reduce transmission are ongoing. There is increasing evidence from observational studies that women taking ARVs are likely to have a low risk of transmission (18).

Five priority areas for national governments in the context of the Global Strategy are proposed in HIV and Infant Feeding: Framework for Priority Action (19) that has been endorsed by nine United Nations agencies:

1. Develop or revise (as appropriate) a comprehensive national infant and young child feeding policy, which includes HIV and infant feeding.
2. Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions.
3. Intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognising HIV as one of a number of exceptionally difficult circumstances.
4. Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies and to successfully carry out their infant feeding decisions.
5. Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.

Counselling about feeding options (20,21)

All women should be made aware of the risk of MTCT in general, and that there is an increased risk of transmission if they become infected during breastfeeding. Women and their partners should be encouraged to accept HIV testing and counselling during pregnancy, so that they know their status, and so that they can take advantage of help that is available and make appropriate decisions before the baby is born.

Counselling about feeding options for HIV-positive women needs to start during pregnancy. HIV-positive women and their partners should be informed about:

• the risks of mother-to-child transmission of the virus;
• feeding options that are appropriate and feasible in the local context, considering national policies;
• the advantages and disadvantages of each feeding option.

They should also be made aware that:

• replacement feeding carries an increased risk for the child of morbidity and mortality associated with malnutrition and infectious diseases other than HIV, when compared with breastfeeding;
• mixed feeding carries both the risk of transmission of HIV and the risk of other infections and is the worst option;
• it is important for the mother to take care of her own health and nutrition, but that breastfeeding will not affect her health adversely;
• giving antiretroviral drugs to either the mother or the infant while breastfeeding can significantly reduce the risk of transmission;
• it is particularly important to practise safer sex when the baby is breastfeeding, because of the greater risk of transmission of HIV to the infant should the mother be infected at this time.

HIV-positive women should be given guidance to help them decide what is the best infant feeding method for their own situation, and they should be taught how to carry out their chosen method safely. Usually, only the two main feeding options (replacement feeding and exclusive breastfeeding) need to be discussed during counselling, but others may be explained if the woman appears interested.

Support for the chosen feeding method

If an HIV-positive mother chooses to give replacement feeding, she will need to be taught how to measure ingredients and how to prepare breast-milk substitutes hygienically (see Box 17) (20,21,22). Programmes should try to improve conditions that make replacement feeding safer for HIV-infected mothers and families (23).

Box 17

Replacement feeding. Replacement feeding is the process of feeding a child who is not breastfeeding with a diet that provides all the nutrients the child needs, until the child is fully fed on family food. Replacement feeding includes replacement of breast (more...)

If an HIV-positive mother chooses to breastfeed her baby herself, she should be given support to help her to breastfeed exclusively (17), with a good technique to ensure a plentiful supply of milk and to prevent mastitis and sore nipples; and guidance about treating these conditions early should they occur (see Session 7.7).

If an HIV-positive mother chooses to stop breastfeeding early, she will need help to change to replacement feeding and to stop breastfeeding completely over a time period of a few days to 2–3 weeks. She will need support to:

• express her breast milk and accustom the baby to cup feeding of EBM;
• gradually reduce breastfeeds, and replace them with EBM;
• change from EBM to replacement feeds given by cup; if the baby is receiving replacement feeds and EBM at the same time, then the EBM should be heat treated;
• comfort the baby by cuddling, rubbing and rocking, and by giving him or her a finger or forearm to suck on. Also accustom the baby to means of comfort provided by people other than the mother;
• keep her breasts healthy, by expressing enough milk to prevent engorgement until milk production stops. The milk should be discarded, or if used to feed the infant, it should be heat treated;
• disclose to a member of the family the reasons for stopping breastfeeding if she has not already done so, and gain the family's support for the transition period.

HIV-positive women who choose to express and heat treat their milk, need guidance on expression, heat treatment, cup feeding and quantities of EBM to give. If a family decides on a wet-nurse, she will need all the support that a breastfeeding mother needs, and counselling about avoiding any risk of HIV infection while she is feeding the baby (24).

All mothers and caregivers should receive follow-up care for at least 2 years to ensure that the child is adequately fed and growing and that other foods are introduced when the child is 6 months old (see Session 3 and below)

Home-modified animal milk is no longer recommended as a replacement feeding option to be used for all of the first 6 months of life. It does not provide all the nutrients that an infant needs, and the micronutrient mix originally recommended to be added to it is not available (25). For women who choose replacement feeding, home-modified animal milk should only be used for short times when commercial infant formula is not available. For infants 6 months of age and older, undiluted animal milks can be added to the diet, and serve as a suitable substitute for breast milk. The recommended volumes are 200–400 ml per day if adequate amounts of other animal source foods are consumed regularly, otherwise 300–500 ml per day (26).

Baby-friendly hospitals and HIV

Baby-friendly hospitals have a responsibility to care for and support both HIV-positive and HIV-negative women.

• If a mother is HIV-positive, and after counselling has chosen replacement feeding, this is an acceptable medical reason for giving artificial feeds, and is thus compatible with a hospital being baby-friendly The staff should support her in her choice, and teach her how to prepare feeds safely. However, they should give this help privately, and not in front of other women who may not be HIV-positive. This is necessary both to comply with the Code, and also to prevent the spillover of artificial feeding to women who do not need it. These women may lose confidence and interest in their own milk if they see replacement feeds being prepared.
• If an HIV-positive mother chooses breastfeeding, the staff have an equal responsibility to support her to breastfeed exclusively, and to ensure that she learns a good technique.
• For women who are HIV-negative or of unknown status, staff should make sure that they are fully informed and supported to breastfeed optimally.

Although baby-friendly hospitals should not accept free or low-cost supplies of breast-milk substitutes from manufacturers or distributors, the government may supply them or the hospital or mothers may purchase them for use during the hospital stay. Only the quantity that is actually needed should be available in the hospital, and distribution should be carefully controlled.

A course for hospital administrators provides guidance for how to implement the baby-friendly Ten Steps in settings with high HIV prevalence (27).

Guiding principles

Sometimes young children between the ages of 6 months and 2 years are not breastfed. Reasons include when their mother is unavailable, or has died, or is HIV-positive. These children need extra food to compensate for not receiving breast milk, which can provide one half of their energy and nutrient needs from 6 to 12 months, and one third of their needs from 12–23 months (26).

To feed children aged 6–23 months satisfactorily, all the principles of safe, adequate complementary feeding apply, as described in Session 3. However, to cover the requirements that would otherwise be covered by breast milk, a child needs to be fed a larger quantity of the foods containing high-quality nutrients.

This can be achieved by giving the child:

• extra meals, to help ensure that sufficient amounts of energy and nutrients are eaten;
• meals of greater energy density, to help ensure that sufficient energy is consumed;
• larger quantities of foods of animal origin to help ensure that enough nutrients are eaten;
• nutrient supplements, if foods of animal origin are not available.

Follow-up of Infants and young children who are not breastfed

The same principles of follow-up and referral apply to non-breastfed children as to breastfed children (see Session 5.6). They should be followed up regularly for at least 2 years to ensure that their feeding is adequate, and that they are growing and remaining well-nourished.

All infants of HIV-positive mothers, at whatever age they stop breastfeeding, should be followed up for at least 2 years to ensure that their feeding is adequate, and to establish if they are HIV-positive themselves.