THE BABY AT BIRTH. Obstetrics Nursing pptx

Midwifery

1. THE BABY AT BIRTH. At birth, the newborn must initiate respiration, establish circulation and maintain its own metabolism. Adaptation to extra uterine life The newborn must transit from intrauterine to extra uterine life. Respiratory changes- the primary concern at the time of delivery is the establishment of respiration.

2. Upon delivery the lungs change from a fluid filled state to a system well prepared for and capable of respiration. A combination of biochemical changes and physical stimuli stimulate the neonate to take the first breath. (Physical stimuli- cold, gravity, pain, light, noise, gentle rubbing of the back, flicking the sole of the foot, drying of infant to reduce heat loss).

3. THE BABY AT BIRTH . CONT`D The first active breaths Converts the fetal circulation into adult circulation Empties the lungs of fluid Establishes the neonatal lung volume and the characteristics of pulmonary function.

4. THE BABY AT BIRTH. CONT`D Circulatory changes – these begin with the clamping of the umbilical cord and the first breath taken by the newborn. There are five attributes of fetal circulation that must be altered for the neonate to make the switch from the fetal to adult circulation. Closure of the ductus arteriosus Closure of the foramen ovale Closure of the ductus venosus Decrease pulmonary vascular resistance (vasodilation of pulmonary arterioles) Increase aortic blood pressure

5. THE BABY AT BIRTH. CONT`D Thermal regulation The neonate loses heat at birth through: Evaporation : wet skin Radiation : body heat transferred from body to cooler objects in the environment Convection: cool air passing over the surface of the body (skin) Conduction : heat lost from the body to other objects in direct contact with the skin

6. THE BABY AT BIRTH. CONT`D When the neonate is exposed to cold in its environment, it will attempt to conserve energy by peripheral vaso -constriction and adoption of a flexed posture ( neonate does not shiver when it is cold). The neonate is capable of producing heat through both general/ white fat and brown fat metabolism. If the neonate is cold the autonomic nervous system triggers the brown fat deposits to release and metabolize the stored brown fat to produce heat (white fat cannot be utilized readily).

7. THE BABY AT BIRTH. CONT`D Heat loss can be minimized by having: Warm delivery room Drying the baby at birth and removing the wet sheet ( immediately it is born) Wrapping baby in warm blanket Placing baby skin-to-skin (on the mother) Covering baby (especially head and feet)

8. THE BABY AT BIRTH. CONT`D Other systems like the gastrointestinal must become functional, urinary system must concentrate and excrete urine and the neurological system must begin the functions that protect and preserve life.

9. Read on the physiology of the newborn covering the following: Respiratory system Cardiovascular system Thermal regulation Renal system Gastrointestinal system Reproductive system Musculoskeletal system Immunological adaption Neurological system Special senses Behavior pattern – sleeping and waking -crying -growth and development

10. Characteristics/Physical Features of the Normal Neonate A healthy neonate born at term has a birth weight of 2.5-3.5 kg, head circumference of 35cm chest circumference 30-33cm . Cries immediately after birth. Establishes independent rhythmic respiration and quickly adapts to the changed environment.

11. Characteristics/Physical Features of the Normal Neonate CONT`D Posture The newborn assumes the attitude of its intra uterine life i.e. extremities flexed and fists clenched.

12. Skin Slight peripheral skin cyanosis ( achrocyanosis ) is common, but soon becomes pinkish with the establishment of cardiopulmonary function. Vernix caseosa covers the skin, particularly the back and creases. Lanugo is present over the face, back and extremities. Mongolian spots (benign bluish pigmentation) may be present over the sacrum and they disappear by 4 years of age.

13. Characteristics/Physical Features of the Normal Neonate CONT`D Head Head is larger in relation to the rest of the body, evidence of varying degrees of moulding are present in vaginally delivered babies with cephalic presentation. Varying degrees of caput succedaneum may be evident ( cephalhematoma is not present at birth). Face The face is comparatively smaller in relation to the head. The eyes remain closed most of the time. The gums are smooth. The cartilages of the ears and nose are well formed and the cheeks are full. Neck The neck is short.

14. Characteristics/Physical Features of the Normal Neonate CONT`D Trunk The chest is barrel shaped. The circumference is less than that of the head. Breathing is abdominal. Heart rate is usually 120-160 bpm. Respiratory rate is usually 40-60 cycles per minute. Abdomen is usually soft. Bowel sounds are audible. Abdomen protrude or may be flat. Genitalia Male- foreskin covers the glans, an orifice is present at the tip. The testes can usually be palpated in the scrotum. Female- the labia minora and clitoris are covered by the labia majora .

15. Characteristics/Physical Features of the Normal Neonate CONT`D Extremities Symmetrical and proportionate to the rest of the body. Temperature- normal body temperature of a neonate is 36.5-37.5 c Urine Small amount of urine with low specific gravity is passed Stool Meconium may be passed soon after birth or within the first 24 hours

16. Characteristics/Physical Features of the Normal Neonate CONT`D Haematological findings Total blood volume is about 300 mls or 85 mls per kg body weight. Clotting power of the blood may be poor because of deficient vitamin K. Newborn reflexes are present at birth.

17. Characteristics/Physical Features of the Normal Neonate CONT`D Average measurements Head circumference – 35 cm Chest circumference – 32 cm Crown rump length – 35 cm Crown heel length – 51 cm

18. IMMEDIATE CARE OF THE NEWBORN (AT BIRTH) When the baby`s head is born wipe the face with sterile swab. Using separate sterile swabs clean the mouth and nose of any liquor or mucus. Swab the eyes using separate sterile swabs from within outwards. Handle the baby gently while it is being drawn up towards the mother`s abdomen (support body with your hand). Note time of baby`s birth Note sex of baby Clear airway if indicated

19. IMMEDIATE CARE OF THE NEWBORN (AT BIRTH ) CONT`D Dry baby thoroughly Evaluate baby`s condition as it being dried (i.e. is baby crying?). Change wet sheet and wrap with clean, dry, warm sheet. Turn baby`s head to the side to facilitate drainage Clamping and cutting the umbilical cord Separation of the baby from the placenta is achieved by cutting the umbilical cord between two clamps after cord pulsations have ceased or 2-3 minutes (1-3 minutes) after birth.

20. IMMEDIATE CARE OF THE NEWBORN (AT BIRTH) CONT`D Identification: When babies are born in the hospital, it is essential that they are identifiable from one another. Name (identification or wrist) bands are used. Apply identification band to baby`s wrist with the following information: mother`s name, sex of baby, date and time of birth.

21. IMMEDIATE CARE OF THE NEWBORN (AT BIRTH) CONT`D APGAR SCORE At one minute after the baby`s birth, assess the baby`s general condition by noting the baby`s appearance, pulse rate, grimace, activity and respiratory effort. This is repeated at five minutes and the scores recorded. Prevent heat loss (keep baby warm) Ensure baby`s skin is dry Keep baby skin-to-skin with mother or place under radiant warmer (or 200 watt bulb) Ensure cot sheet, blanket or cloth is warm Cover baby`s head

22. APGAR SCORE CONT`D Replace initial cord clamp with disposable plastic clamp (Hollister clamp) or cord ligatures and cut off excess cord. Show baby to mother to identify sex Initiate breastfeeding Apply prophylactic eye drops or ointment against gonococcal infection within one hour of birth Give injection vitamin K 1 mg (or 0.5 mg) as prophylaxis against bleeding disorders.

23. SUBSEQUENT CARE OR DAILY CARE AND OBSERVATION OF THE NEWBORN The daily assessment is important for identification of early problems if the baby is found to be normal after the initial assessment, the following should be done daily: Check vital signs and record Check weight every three days and record. Weight loss is normal in the 1 st few days. Most babies regain their birth weight in 7-10 days, thereafter gaining weight at a rate of 150-200 grams per week. General changes in color and activity. Cyanosis. Jaundice may be noted from third day (it is abnormal if it is detected earlier, deepens or persists beyond the 7 th day)

24. SUBSEQUENT CARE OR DAILY CARE AND OBSERVATION OF THE NEWBORN CONT`D Feeding status. The amount taken and any difficulties are to be observed and recorded. The head. Assessment of the anterior fontanelle , which should be level, resolution of caput succedaneum and moulding and identification of any new swelling such as cephalhaematoma . The mouth should be clean and moist. Adherent white plagues indicate oral thrush infection Umbilical cord base is inspected and cleaned daily (after bath or top and tail)

25. SUBSEQUENT CARE OR DAILY CARE AND OBSERVATION OF THE NEWBORN CONT`D Elimination: the stools are observed and compared with expectations in relation to the baby`s age and feeding method. Meconium present in the large intestine is passed within the first 24 hours of life and is totally excreted within 48- 72 hours. The first stool is blackish green in color, is tenacious and contains bile, fatty acids, mucus and epithelial cells. From the 3 rd to 5 th day, the stools are brownish-yellow in color. Once feeding is established yellow stools are passed. The consistency and frequency of stools reflect the type of feeding. Breast milk- loose, bright yellow and inoffensive acid stools (passes 8-10 stools a day). Formula- paler in color, semi-formed less acid and have a slightly sharp smell. (Passes 4-6 stools a day with increased tendency to constipation). Constipation, loose stool or sore buttocks may be observed and noted. The frequency of passing urine and stools in the past 24 hours should be noted.

26. SUBSEQUENT CARE OR DAILY CARE AND OBSERVATION OF THE NEWBORN CONT`D Bath: cleansing the skin may be done daily or as frequently as required or top and tailing; the face, skin flexures and napkin area must be cleaned. As the baby is undressed, the skin is inspected for rashes, septic spots or abrasions. Parent-infant interaction: practice of rooming-in and bedding-in Immunization: BCG and Polio O.

27. MINOR DISORDERS OF THE NEWBORN AND MANAGEMENT SORE BUTTOCKS Sore buttocks is the reddening followed by excoriation and sometimes ulceration of the skin on the buttocks and around the perianal regions. Causes It is caused by acid stools and ammonia dermatitis. This occur as a result of infrequent changing of the napkin and frequent stools.

28. SORE BUTTOCKS CONT`D Treatment Keep the skin around the buttocks and perineum clean and dry by changing napkins immediately they are soiled with urine or faeces . Wash the skin of the buttocks with soap and water, dry thoroughly and apply antiseptic powder or cream example Vaseline, zinc and castor oil ointment. Prevention Changing napkins regularly (immediately it is soiled) Washing the skin of the buttocks with soap and water, drying it thoroughly and applying Vaseline into the skin before putting on a clean napkin.

29. ENGORGED BREASTS (MASTITIS NEONATORUM) Engorged breasts occurs in babies of both sexes . Causes It is due to intra-uterine stimulation of the breasts by maternal hormones ( oestrogens ) supplied through the placenta. It occurs after the third day of life Signs The breasts are swollen, hard and hot, fluid called “witch milk” may be present in the breasts.

30. ENGORGE BREASTS (MASTITIS NEONATORUM ) CONT`D Treatment Advise the mother against squeezing or undue manipulation of the engorged breasts. She should also avoid application of fomentation Assess the breasts: if warm and red, swollen and tender, check temperature Give suspension flucloxacillin and monitor progress If abscess develops, take discharge material for C/S Incise and drain abscess Start specific antibiotic therapy

31. SKIN RASHES Heat rash is common in hot countries. The rash is evident as pinpoints on the skin which are more numerous at the skin folds. Application of antiseptic dusting powder and the use of light clothing clears up such rashes. Rash due to staphylococcal infection is often pustular (i.e. it contains pus) and is referred to as septic spots. This type of rash can spread easily and should be taken care of. A baby who has become infected should be isolated.

32. SKIN RASHES CONT`D Assess the size of the lesions. If limited, apply gentian violet and advise on hand washing before handling baby. If lesion is extensive and there is fever or if there is no improvement after 72 hours of treatment: give suspension cloxacillin 62.5mg q.i.d for 5-7 days. Monitor progress: if there is no improvement after 72 hours or if condition worsens (i.e. signs of systemic infection –fever, jaundice and vomiting) occurs do lab investigations including: skin swab for C/S, F.B.C, and blood culture.

33. SKIN RASHES CONT`D Institute prompt specific antibiotic therapy. An antiseptic and drying agent such as Hibitane (1:2000) in spirit or a 1% aqueous solution of gentian violet is useful (apply on lesion)

34. PSEUDO-MENSTRATION This is a blood-stained vaginal discharge in female babies. It is probably due to withdrawal of oestrogen . It usually disappears after a day or two. The mother needs to be reassured that it will resolve on its own.

35. CONSTIPATION Constipation is best considered in terms of the consistency of the stool rather than the frequency (number of times) of defaecation . It may be normal with some babies to defaecate once in two days provided the stools are soft. Constipation is not common with breast fed babies. The stools of constipated babies are infrequent and hard, therefore the child strains when defaecating .

36. CONSTIPATION CONT`D Remedy Some experienced midwives advocate stimulation of the anal sphincter with a lubricated fingertip or suppositories. Give extra fluids and sugar or orange juice to the baby. Milk of magnesia – a teaspoonful twice daily may be given. A doctor must be consulted if the above measures fail or if there is abdominal distension laxatives and drastic enemas must be avoided.

37. VOMITING Vomiting is the ejection of the stomach contents through the mouth. This is usual in young babies during the first 24 hours of life. Mucus and shreds of blood swallowed at birth are gotten rid of this way. Sometimes it may be necessary to give the baby some 5 percent glucose drink to act as a lavage. A stomach tube may be passed and the stomach aspirated if this initial vomiting is persistent. Sometimes what is regarded as vomiting maybe posseting and or regurgitation.

38. VOMITING CONT`D Posseting is the welling out of some small amounts of feed retained in the baby`s buccal cavity or mouth. Regurgitation occurs usually because the cardiac sphincter of the stomach is not functioning properly. Therefore, some feed comes into the oesophagus and the mouth to be poured out. Regurgitation often occurs in connection with the breaking of wind or expulsion of gas from the stomach and it is more common in premature babies.

39. VOMITING CONT`D When a baby vomits, the nurse must observe the following: The association of the vomiting with feeds The force with which the feed is returned The amount, odor, color and constituents of the vomitus.

40. VOMITING CONT`D Presence of bile or faecal matter in a baby`s vomitus is serious. It means that the vomiting is of long duration and that nothing is retained in the baby`s stomach. The presence of signs such as dehydration, poor appetite, diarrhea and constipation makes it a more serious sign. In such circumstances, medical aid must be sought immediately.

41. VOMITING CONT`D Most babies vomit because of faulty feeding techniques: these are: Taking the feed too quickly Failure to break up wind Rough handling of the baby after feeds.

42. VOMITING CONT`D Advice should be given to correct these faults. Also a review of the amount and strength of an artificial feed (whenever it is used) must be made. Provided a baby does not lose weight or show signs of dehydration and ill health, vomiting in a thriving baby may be ignored.

43. HIV AND INFANT FEEDING All mothers with HIV should receive counselling to guide them to choose infant feeding options suitable for their situation.

44. HIV AND INFANT FEEDING CONT`D Policy statement supporting breast feeding As a general principle, in all populations, irrespective of HIV infection rates, breast feeding should continue to be protected, promoted and supported.

45. HIV AND INFANT FEEDING CONT`D For infant` growth and development, breast milk supplies all the nutrients their bodies need during the first 6 months of their live. In addition breast milk strengthens their immune system. However, HIV can pass from infected mother to her baby during breast feeding and care must be taken to reduce the transmission risk. For this reason all pregnant women or new mothers with HIV need counselling which includes: Information about the risks and benefits of various locally appropriate infant feeding options. Guidance in selecting the most suitable infant feeding option for their situation. Whatever a mother decides, she should be supported in her choice.

46. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS The most appropriate infant feeding option for an HIV infected mother should continue to depend on her individual circumstances, including her health status and the local situation, but should take greater consideration of the health services available and the counselling and support she is likely to receive.

47. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS CONT`D Exclusive breast feeding is recommended for HIV infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, suitable and safe (AFASS) for them and their infants before that time. When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV infected women is recommended.

48. What is exclusive breastfeeding? Exclusive breast feeding is feeding the baby only breast milk without giving other liquids or solids, not even water, with the exception of medically indicated drops or syrups consisting of vitamins, mineral supplements or medicines.

49. What is replacement feeding? Replacement feeding is feeding the baby who is receiving no breast milk, with a diet that provides all the nutrients that the child need, until the age at which the baby can be fully fed on family food. During the first six months of life, replacement feeding should be with a suitable breast milk substitute only. After six months, the suitable breast milk should be complemented with other foods.

50. Questions to consider with replacement feeding. Acceptable to the mother and her family and community. Feasible, the mother and family have time, knowledge, skills and means to prepare the replacement feeds correctly various times a day, every day? Affordable, taking into account all the costs, including milk, water, fuel, soap, equipment and other needs including medical expenses in case the child become sick from unsafe preparation and feeding practices? Sustainable, there is a continuous availability of supply and reliable system of distribution of all ingredients and products needed for as long as the infant needs it up to one year or longer? Safe in that replacement foods are correctly and hygienically prepared, stored and fed in enough quantities with clean hands using utensil preferably by cups.

51. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS CONT`D REPLACEMENT FEEDING EXCLUSIVE BREAST FEEDING BENEFITS BENEFITS No risk of transmission of HIV from the mother to the infant. Spares the mother`s nutrients store, reducing her risk of infections Other members of her household can be involved in the infant`s feeding. Breast milk contains all the food the baby needs for the first 6 months. Breast milk is easy to digest. Does not need water. Breast milk protects the baby from diarrhea, pneumonia and other infections. It is free, always available and does not need any special preparation. It creates a bond between a mother and her baby. Exclusive breastfeeding helps mothers recover from childbirth and protects them from getting pregnant again too soon. Exclusive breast feeding for the first few months has a lower risk of transmitting HIV to the infant.

52. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS CONT`D REPLACEMENT FEEDING EXCLUSIVE BREAST FEEDING RISKS RISKS Non-HIV infections such as diarrhea and chest infections since the infant will not have the protective antibodies obtained from breast milk. The expense of obtaining the appropriate foods for the baby as well as clean water and fuel. Questions that may be raised by others about the mothers with HIV status because she is not breastfeeding. As long as the baby is breastfed, the risk of passing HIV to the baby exists. The mother will need additional energy to support the demands of breastfeeding. Other people may pressurized the mother to give water and other liquids or foods to the baby while she is breastfeeding. This practices known as mixed feeding increases the risk of HIV transmission for mother to baby as well as diarrhea and other infections.

53. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS CONT`D Transmission of HIV during pregnancy and delivery is approximately 20-25% without a ntiretroviral drug treatment. Transmission during pregnancy and delivery is reduced to 12-13% with Nevirapine and 6-8% with AZT + Nevirapine . If there is no intervention to prevent mother to child transmission of HIV, 24-45% of HIV infected mothers will pass on the virus to their child. About 5-20% of these will be through breastfeeding, especially for a longer period of 18 months and above including mixed feed which may increase the viral load in breast milk. If a woman knows she is HIV-positive, during her pregnancy, it is a good time to think and plan on how she will feed her baby. One can talk to her doctor, nurse, or HIV counsellor to help her decide the best way to feed her baby in her situation and provide support to carry on the chosen feeding option.

54. RISKS AND BENEFITS OF DIFFERENT FEEDING OPTIONS FOR INFANTS WITH HIV POSITIVE MOTHERS CONT`D When you discuss infant feeding with a mother who is HIV positive also discuss how she will carry out her decision. If she has not disclosed her status, she will have hard time getting necessary support she needs to feed her baby. Infant feeding counsellor can help women make decision about disclosing their status. Help her to get more information on safer breast feeding practices and how to eat wisely to build and store nutrients needed for her body and for milk production.

55. TALK FOR PREGNANT WOMEN WHO ARE HIV POSITIVE ON FEEDING THEIR BABIES If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is recommended for the first six months, continuing thereafter with the addition of complementary foods. If a woman is HIV-positive, she should be counselled and helped to decide how to feed the baby , before the baby is born. If breastfeeding is chosen, she should breastfeed exclusively for the first few months and change to replacement feeding when acceptable, feasible, affordable, sustainable and safe. The risk of HIV transmission is highest in those who use mixed feeding (receiving both breastfeeding and other foods or fluids) and it should be avoided.

56. TALK FOR PREGNANT WOMEN WHO ARE HIV POSITIVE ON FEEDING THEIR BABIES CONT`D Ensure good hygiene and encourage mothers to breastfeed on demand, that is as often as the baby wants to feed. This will stimulate milk production and keep her breasts from getting engorged or swollen. Encourage good breastfeeding techniques to prevent sore nipples and breast problems. If these occur they should be treated promptly. When a mother decides to breastfeed (provision of on-going support to mothers), it is important that she receives support to continue this decision and to breastfeed exclusively. Mothers also need help that will enable them to minimize the risk and discomfort during the transition from exclusive breastfeeding to complementary feeding.

57. over of HIV and Infant Feeding After completing this session participants will be able to: Explain the risk of mother to child transmission of HIV Describe factors which influence mother-to-child transmission Describe the importance of antiretroviral drugs in reducing mother-to-child transmission of HIV and in increasing HIV free survival in infants. Support HIV positive women to replace feed according to national authority recommendations. Describe the conditions required for replacement feeding. Support HIV positive women who choose to breastfeed.

58. Defining HIV and AIDS HIV Human immunodeficiency virus is the virus that causes AIDS Acquired immunodeficiency syndrome is the active pathological condition that follows the earlier, non-symptomatic state of being HIV infected or HIV –positive.

59. HIV and Infant feeding: what is new? Significant programmatic experience and research evidence regarding HIV and feeding have accumulated since 2006. in particular Evidence has been reported that for antiretroviral (ARV) interventions for either the HIV-infection mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding.

60. Mother –to-child transmission of HIV Young children who get HIV are usually infected through their mothers During pregnancy across the placenta At the time of labour and birth through blood and secretions. Through breastfeeding or breastmilk . This is called mother-to-child transmission of HIV or MTCT.

61. Estimated risk and timing of mother- to-child transmission of HIV in the absence of interventions Timing of MTCT of HIV transmission rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% Overall without breastfeeding 15-25% Overall with breastfeeding to 6 months 20-35% Overall with breastfeeding to 18-24 months 30-45%

62. Factors which affect mother-to-child transmission of HIV through breastfeeding Recent infection with HIV Severity of disease Sexually transmitted infections Obstetric procedures Duration procedures Duration of breastfeeding Exclusive breastfeeding or mixed feeding Condition of the breasts Condition of the baby’s mouth

63. Estimated risk and timing of mother-to-child transmission of HIV with intervention Timing of MTCT of HIV Transmission Rate During pregnancy 0-1% During labour and delivery 1-2% Breastfeeding 0-12mths 2-3%

64. WHO INFANT FEEDING RECOMMENDATIONS

65. Main Infant feeding recommendation (1) for HIV positive women Mother known to be HIV-infected should be provided with lifelong ARV treatment or ARV prophylaxis to reduce HIV transmission through breastfeeding (recommendation 1) ARVs reduce the risk of HIV transmission in the first 6 months when infants continue to breastfeed while taking complementary feeds. ARVs are given either as lifelong treatment (ART) or as ARV prophylaxis i.e. for prevention during the period of brestfeeding only. When given as prophylaxis, ARVs should be taken by both mother and baby until one week after all breastfeeding stops

66. Main infant feeding recommendation (2 and 3) for HIV positive women HIV positive mothers should exclusively breastfeed their infants for the first 6 months, introduce appropriate complementary foods thereafter and continue breastfeeding until baby attains 12 months ( Recom . 2) When deciding to stop breastfeeding, HIV positive mothers should do so gradually within 1 month ( Recom . 3)

67. Conditions needed to safely formula feed (Recommendation 5) HIV-infected mothers should only give commercial infant formula milk as a replacement feed to their HIV-negative infants or infants who are of unknown HIV status, when specific conditions are met: Safe water and sanitation are assured at household level and in the community. The mother or other care giver can reliably provide sufficient infant formula milk to support normal growth and development. The mother of care giver can prepare it clearly and frequently enough so that it is safe and carries a low risk of diarrhea and malnutrition. The mother or care giver can in the first 6 months, exclusively give infant formula milk. The family is supportive of this practice The mother or caregiver can access health care that offers comprehensive child health services NO MORE AFASS

68. When the infant is HIV-infected (recommendation7) If infant and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first 6 months of life and continue breastfeeding as per the recommendations for the general population that is up to two years or beyond.

69. Policy of supporting breastfeeding ‘As a general principle, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported’ HIV and infant feeding a policy statement developed collaboratively by UNAIDS, who and UNICEF, 1997

70. New PMTCT ARV recommendation are based on these two k ey areas Lifelong ART for HIV-positive women in need of treatment for their own health, which is also safe and effective in reducing MTCT. ARV prophylaxis (short term) to prevent MTCT during pregnancy, delivery and breastfeeding for HIV-infected women who do not need treatment for their own health.

71. The 2010 WHO guidelines on PMTCT and infant feeding Include new evidence on: The best time to start antiretroviral therapy (ART) in women who need treatment for the disease. The use of antiretroviral (ARV) prophylaxis to prevent mother-to-child transmission of HIV including during breastfeeding. Safe feeding practices for HIV-exposed babies

72. ARV prophylaxis to prevent MTCT For HIV + women not eligible for ART Two possibilities Option A: Maternal triple ARV prophylaxis Begin as early as 14 weeks gestation (2 nd trimester) or as soon as possible thereafter. With Option B+, all HIV positive pregnant women are immediately started on lifelong treatment.

73. supporting HIV positive women to USE REPLACEMENT FEEDING What is replacement feeding? The process of feeding an infant or young child, who is not receiving any breast milk, with a diet that provides all the nutrients needed. Note that the conditions needed to safely formula feed should be adhered to

74. What to feed infants when mothers stop breastfeeding When HIV + ve mothers stop breastfeeding at anytime, infants with safe, adequate replacement feeds to enable normal growth and development. Alternative to breastfeeding include: FOR INFANTS LESS THAN 6 MONTHS Commercial infant formula milk if home conditions are as outlined in Recom.5 Expressed heart treated breastmilk ( eg . Cow milk or goat milk) FOR CHILDREN OVER 6 MONTH Commercial infant formula milk if home conditions are as outlined in Recom.5 Animal milk as part of diet providing adequate micronutrient intake-boll for infants under 12 months Meals, including milk-only, other foods and combination of milk and other foods should be provided 4 or 5 times per day. All children need complementary foods from six months of age

75. Infant feeding recommendations for HIV-positive women Replacement feeding should meet the new WHO recommendation (5), which have the conditions needed to safely formula feed. Otherwise, exclusive breastfeeding is recommended during the first 6 months of life, then continue with complementary foods whilst still breastfeeding till child is 12 months old. Note: It is recommended that children 6 months and above are given other family foods in addition to breastmilk which is guided by: AFATVRH (Age, Frequency, Amount, Thickness, Variety, Responsive feeding, and Hygiene)

76. ANY QUETIONS?