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Research highlights
In this section, the IYCN Project offers summaries of new and notable research related to maternal, infant, and young child nutrition. Each summary includes the findings and analysis of the study’s author(s) only. Check back periodically for new research highlights.
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Kesho Bora study: Maternal anti-retroviral therapy during pregnancy and breastfeeding prevents more infections than short-course prophylaxis
July 2009
The Kesho Bora study in Kenya, South Africa, and Burkina Faso investigated whether giving highly active anti-retroviral therapy (HAART) to women with CD4 counts between 200 and 500 cells/mm3 during pregnancy, labor, and through six months of breastfeeding reduced vertical HIV transmission compared to short-course therapy from weeks 28 to 36 through one week after delivery. Investigators found no difference in transmission rates from birth through the first week of life, but did find a significant reduction in risk of transmission by one year of age in the HAART group. Sub-group analysis showed that the significant difference was confined to women with CD4 counts between 200 and 350 cells/μL. Among those women, the HIV transmission rate at 12 months was 6.1% in the HAART group, compared to 11.1% in the short-course group. The HIV-free survival rate for the entire HAART group was 89.6% at 12 months compared to 83.7% in the short-course group, indicating a 36% risk reduction with HAART.
Among women who received HAART and had CD4 counts less than 200 cells/μL, risk of death or HIV was 26.7% among infants who were never breastfed compared to 10.8% if they were breastfed. This finding suggests that treatment for eligible women plus breastfeeding provides the best protection for HIV-exposed infants.
Visit the IAS 2009 website to learn more.
Mma Bana study: Mother-to-child transmission reduced to less than 1% in breastfeeding mothers who receive ART
July 2009
The Mma Bana study in Botswana explored the relative efficacy of two ARV regimens (Trizivir and Kalatera) for women with CD4 counts more than 200 cells/μL, taken from 26 weeks of pregnancy through six months of breastfeeding. The primary outcomes of interest were viral load suppression and mother-to-child transmission of HIV from birth through six months. A third arm contained women with CD4 counts less than 200 cells/μL that qualified for nevirapine-based treatment under current guidelines. Viral suppression less than 400 copies/mL was greater than 90% in all arms. HIV transmission during all periods was extremely low in all arms and not significantly different. Almost all transmission happened in utero among women who were on ART for shorter periods of time and had higher baseline viral loads. The cumulative rate of HIV transmission at six months was 1%. Only two infants were infected during breastfeeding. Lower rates of transmission in this study compared to Kesho Bora may be attributed to higher baseline CD4 counts, longer duration of HAART during pregnancy, and a 93% rate of exclusive breastfeeding through the time of breastfeeding cessation. The Mma Bana transmission rates were similar to those found in the previously published Amata study in Rwanda. In the Amata study only one infant became infected through breastfeeding when mothers took HAART from 28 weeks ante partum through six months of breastfeeding.
Visit the IAS 2009 website to learn more.
Breastfeeding, Antiretroviral, and Nutrition study: Giving ART to mothers or ARV prophylaxis to infants during breastfeeding equally effective at reducing HIV transmission
July 2009
The Breastfeeding, Antiretroviral, and Nutrition (BAN) study investigated the efficacy of giving either maternal HAART or daily nevirapine to prevent mother-to-child transmission of HIV during 24 weeks of exclusive breastfeeding and a four-week weaning period. A control arm received short-course therapy plus nutritional supplementation. Both interventions yielded statistically significant reductions in HIV infection rates and increased HIV-free survival. Among infants uninfected at birth, 28-week infection rates were 1.8% in the infant nevirapine arm, 3% in the maternal HAART arm, and 6.4% in the control arm. Rates of infection or death in those arms were 2.9%, 4.7%, and 7.6%, respectively. The study was not powered to compare the efficacy of the two intervention arms but demonstrated that both infant and maternal interventions can be effective for reducing mother-to-child transmission of HIV from breast milk. These findings are similar to those from the previously published Mitra and Mitra plus studies in Tanzania. Both studies showed an approximate 1% transmission risk between six weeks and six months with maternal HAART or infant prophylaxis through six months.
Visit the IAS website to learn more.
Analysis of outcomes and costs for school feeding programs
October 2009
In a study to be published in the Food and Nutrition Bulletin in October, researchers calculated the per-child cost of school feeding programs in Lesotho, Kenya, The Gambia, and Malawi. By combining their data with a recent meta-analysis on the impact of school feeding on attendance, growth, and cognitive ability, the study also estimated the cost for achieving improvements in those outcomes. The authors found that the average cost of providing 700 kcal for 200 days was $40 per child, ranging from $28 in Kenya to $63 in Lesotho. That is double the World Food Program’s most recent cost estimate of $20 per child, which may be attributable to this study’s inclusion of costs to local governments and communities, as well as consideration of food pipeline breaks. The cost for a child achieving an additional centimeter of height or kilogram of weight was the highest, ranging from $112 to $252. An additional day of attendance cost between $4.70 and $15.80. Other school health interventions, such as deworming, iron supplementation, and malaria prevention, have been estimated to cost less than $4 per year. However, the authors note that their costing analysis may be more complete than those done for other health interventions. Moreover, the cost of school feeding programs could be reduced by purchasing locally grown commodities, which would require far less expenditure for transport and handling, as food accounted for more than 50% of overall costs in every country.
School feeding: outcomes and costs
Integrated Management of Childhood Illness’ impact in Bangladesh
August 2009
In a cluster randomized trial published in the Lancet in August 2009, investigators evaluated the impact of the Integrated Management of Childhood Illness (IMCI) strategy on health worker skills and support, care-seeking practices, feeding practices, growth, and mortality in children under five in rural Bangladesh over a period of six years. The investigators introduced new IMCI initiatives to provide health worker training, improve health systems, and support family and community activities. During the years of intervention, the investigators made several adjustments to improve case management, including development of a new cadre of village health workers. While both intervention and non-intervention areas experienced improvements in health statistics and a decrease in child mortality during the six years, children in IMCI areas were more likely to be exclusively breastfed and less likely to be stunted. Children in IMCI areas also were more likely to be properly treated for diarrhea, a finding that may contribute to the reduction in stunting. While no statistical significance in child mortality was found, child mortality was more than 13% lower in IMCI areas during the last two years of the study.
Folic acid + iron + zinc supplementation for pregnant women improves growth outcomes for kids in Nepal
July 2009
A previous randomized controlled trial provided daily supplementation of one of five micronutrient combinations to pregnant women in Nepal: folic acid, folic acid + iron, folic acid + iron + zinc, multiple micronutrients, or a control. In a recent study published in the Journal of Clinical Nutrition, investigators examined the growth outcomes of the mothers’ children at age 6 to 8 years old. The only micronutrient formulation to show an effect on growth was folic acid + iron + zinc, which resulted in a significant increase in mean height and reductions in tricep skinfold thickness, sub-scapular skinfold thickness, and arm fat area, but no difference in arm muscle area. The effect of the micronutrient combination was most pronounced in children born to stunted mothers (<145 cm) and to mothers with higher body mass index during pregnancy. While a recent meta-analysis found little benefit in supplementing pregnant women with multiple micronutrients rather than just iron and folic acid, based on these growth outcomes the authors suggest further exploration of the potential benefits of adding zinc to the standard iron/folic acid supplement.
Continued breastfeeding increases HIV-free survival for infants in Zambia
June 2009
The Zambia Exclusive Breastfeeding Study randomized HIV-positive mothers to wean their infants at four months (intervention) or to continue breastfeeding for as long as they wished (control). Although nearly 40% of the intervention mothers did not follow the instructions to stop breastfeeding at four months, analysis showed that there was no difference in HIV-free survival between those in the intervention group that adhered and those that did not and continued breastfeeding beyond four months. In a new paper published in PLOS One, the authors conducted a secondary analysis, based on the previous study findings, to investigate whether maternal disease severity modified the relative risks of HIV infection and death associated with adherence to the intervention. Infants of women with less severe disease who stopped breastfeeding at four months were more than two times as likely to die or acquire HIV compared to infants who breastfed longer. Conversely, early weaning among women with more advanced disease had a protective effect. Among infants whose mothers had higher CD4 counts (less severe disease), breastfeeding continued to have a protective effect until the age of 15 months, with those weaned earlier more than three times as likely to die or become HIV-infected. The authors conclude that continued breastfeeding has a protective effect among women with CD4 counts above about 300 cells/ul and that appropriate initiation of anti-retroviral therapy among women with more advanced disease would reduce the risk of postnatal transmission and enable safe continuation of breastfeeding.
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