Breast feeding in special cases

Hello Awesomites!

-HIV positive mother
-Active Pulmonary TB
-Working mothers



CONTRAINDICATION OF BREASTFEEDING :

• HIV, HTLV-1 and 2

• Inborn error of metabolism LIKE GALACTOSEMIA AND PHENYLKETONURIA

• Untreated case of tuberculosis

• Herpes lesion on mothers’ breast

• Mother on certain medication like anti-cancer drug or radioactive isotope etc.

WITH INCREASED BURDEN OF HIV AND TB,INDIA CAN’T AFFORD TO  CONTRAINDICATE THE BREASTFEEDING.

1. IS THERE ANY RELATION BETWEEN BREASTFEEDING AND RISK OF TRANSMISSION?
2. DO ART HAS ANY ROLE TO DECREASE THE TRANSMISSION?

ARV INTERVENTION	RISK OF HIV TRANSMISSION FROM MOTHER TO CHILD
NO ARV                 BREASTFEEDING +	30-45%
NO ARV                 BREASTFEEDING -	20-25%
3ARVS(ART)         BREASTFEEDING +	2%
3ARVS(ART)         BREASTFEEDING -	1%

HOW TO KNOW THE HIV STATUS OF CHILDREN LESS THAN 18 MONTHS?
 
METHOD USED - DNA PCR on a DRIED BLOOD SAMPLES OF INFANT
TEST PERFORMED -

• 6 WEEKS

• 6 MONTHS

• 6 WEEKS AFTER CESSATION OF BREAST FEEDING (if being EBF)

• 18 MONTHS

PEDIATRIC COMPONENT IN PPTCT

• DURATION OF NEVIRAPINE PROPHYLAXIS TO HIV EXPOSED INFANT SHOULD BE MINIMUM OF 6 WEEKS.

• INITIATION OF BREAST FEEDING WITHIN AN HOUR OF DELIVERY AS THE PREFERED OPTION

• CONTINUE BF ATLEAST FOR 1 YEAR FOR THOSE WITH HIV -VE STATUS  AND 2 YEARS FOR HIV +STATUS OF CHILDREN

• ENSURE INITIATION OF CO TRIMOXAZOLE PROPHYLACTIC THERAPY AT 6 WEEK OF AGE

MATERNAL COMPONENT IN PPTCT
“ART TO ALL PREGNANT AND BREASTFEEDING WOMEN LIVING WITH HIV “

TARGET POPULATION	ART REGIMEN
PREGNANT AND BREAST FEEDING WOMEN WITH HIV  BUT NOT ON ART	TDF+3TC+EFV
PREGNANT WOMEN AND BREAST FEEDING WOMEN WITH HIV AND RECIEVING ART	THE SAME ART REGIMEN MUST BE CONTINUED

  
AFASS
 
AFASS CRIETRIA is used to decide whether a HIV positive mother can breast feed or not provided that she has not started top feed yet.
(Why? Once the mother started to top feed the child, this criteria is not used. HIV positive mother in such case should continue top feed. Because mixed kind of feed is more dangerous than top feed alone)

• Acceptable: The mother perceives no problem in replacement feeding.

• Feasible: The mother (or family) has adequate time, knowledge, skills, resources and support to correctly mix formula or milk and feed the infant up to 12 times in 24 hours.

• Affordable: The mother and family, with community or health system support if necessary, can pay the cost of replacement feeding without harming the health or nutrition status of the family.

• Sustainable: Availability of a continuous supply of all ingredients needed for safe replacement feeding for up to one year of age or longer.

• Safe: Replacement foods are correctly and hygienically prepared and stored, and fed preferably by cup.

QUESTIONS

1. Where do you get your drinking water?
2.  What kind of latrine/toilet do you have?
3.  How much money could you afford for formula each month?
   Ps: calculate the amount based on the local costs
    
4. Do you have a refrigerator with reliable power?
    
5. Can you prepare each feed with boiled water and clean utensils?
    
6. How would you arrange night feeds?
    
7. Does your family know that you are HIV positive?
    
8. Is your family supportive of milk feeding and are they willing to help

MANAGEMENT OF BABY BORN TO MOTHER WITH TUBERCULOSIS:-

• Continue exclusive breastfeeding till 6 months of age & thereafter as in normal population.

• Start ATT for mother immediately. Mother will be non infective within 2 months of regular ATT

• Preventive Chemotherapy for baby (INH 5 mg/kg/day for 6 months)

• Use face mask while around the baby, till 2 months after starting ATT.

• BCG Vaccine at birth.Something is better than Nothing!

• Re- immunized with BCG after stopping Preventive Chemotherapy. 
• (Remember, it's not only mother, Anybody (with TB) around can infect the baby with Tuberculosis!)

Is ATT drug concentration in breast milk sufficient for the baby? NO

NAME OF THE GROUP	BREAST FEEDING	BARRIER METHOD	ISOLATION	BCG VACCINATION
IAP	TO CONTINUE	COUGH HYGIENE	1.IF MOTHER ON TREATMENT -NOT REQUIRED 2.IF MOTHER HOSPITALIZED, NON-ADHERENT TO THERAPY,MDR-TB - ISOLATION REQUIRED	AT BIRTH  OR  EVEN WITH INH PROPHYLAXIS
DOTS	ONLY IF MOTHER IS SPUTUM NEGATIVE	FACE MASK	IF MOTHER HAS ACTIVE DISEASE,NON-COMPLIANT AND HAS RECIEVED ATT PRIOR TO DDELIVERY	POSTPONED OR DONE WITH INH RESISTANT OF BCG VACCINE
AAP	ONLY IF MOTHER IS ON ATT	FACE MASK	MDR -TB AND NON COMPLIANT	GIVE BCG IN THESE MDR TB MOTHER
WHO	TO CONTINUE	FACE MASK	MDR -TB	INH THERAPY COMPLETED THEN AFTER 2 WEEK  OF COMPLETION BCG VACCINE GIVEN

 THE DOUBT OF WORKING MOTHERS :-

For How long can expressed breast milk is stored? 

AT ROOM TEMPERATURE	8-10 HOURS
IN A REFRIGERATOR	24 HOURS
IN A DEEP FREEZER (-20 degree)	3 MONTHS

HAPPY STUDYING ! 
-UPASANA Y.

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Kleihauer–Betke test

Kleihauer–Betke test: KB test.

1) Why do we do this test?

- To calculate Fetal RBCs in blood. This helps us to measure amount of Anti-D required to neutralize it.

2) How do we do it?

- Basically, we are going to take blood sample and add acid to it and measure red blood cells under microscope.

3) How do you differentiate Fetal and Maternal blood?

- Fetal RBCs are acid resistant. Adding acid in the preparation leads to lysis of the Maternal RBCs.

4) What are important points regarding this test that should be kept in mind while solving MCQs?

- Do not confuse it with APT test. APT is done in Alkali and it is a Qualitative test. It helps in differentiating Maternal and Fetal blood only. On the other hand, in KB test (Also know as Acid dilution test), we use Acid and we quantify Fetal blood.

- Minimum dose even after KB test is 300 microgram.

5) How do we calculate amount of Anti-D required to neutralize Fetal RBCs?

- If 20 RBCs in HPF are seen, then it means 1 ml Fetal blood is in circulation.

-‎1 ml fetal blood requires 10 microgram of Anti-D for neutralization

6) What if they don't mention "Fetal RBCs" and instead, mention "Fetal blood" in the question?

- Here is a trick. Always remember, 1 ml Fetal blood has 0.5 ml Fetal RBCs.

Applied calculations:

Q1) A Multigravida with twin pregnancy has 20 ml Fetal RBCs. How much Anti-D will be required to neutralize it?

(Take a deep breath. You don't need to worry about twin pregnancy. All the important points are already covered in above segment)

- 20 ml Fetal RBCs = 40 ml Fetal blood.
- ‎1 ml Fetal blood = 10 micrograms Anti-D

Answer = 400 micrograms Anti-D

400 micrograms is the enough amount of blood given to neutralize 40 ml fetal blood or 20 ml Fetal RBCs.
‎
(Done easily? Perfect ! Let's level up.
I want you to go through blog once again before heading down.)

Q2) This time patient comes with same clinical presentation but with 20 ml fetal blood.

- 1 ml fetal blood = 10 micrograms of the Anti-D
- ‎20 ml Fetal blood will require 200 micrograms Anti-D.

Perfect. We calculated correctly but my question is - Will you administer 200 micrograms Anti-D to the patient showing 20 ml Fetal blood to neutralize it?

Answer is big 'NO'.

Go back to bullet (4) point 2:

Minimum amount is still 300 micrograms after KB test. So you cannot administer 200 micrograms. You have to give 300 micrograms.

I hope this blog is better than my previous blogs. Any important points you have regarding KB test, do comment in comment box

That's it

-Demotional bloke