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Mothers, Babies and AIDS

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Summer 1999
Mothers, Babies and AIDS
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The health crisis in Africa challenges the notion that breast-feeding is always best in developing countries
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By E. Richard Stiehm

The late Derrick Jelliffe, a professor of public health and pediatrics at UCLA and the former chair of pediatrics at Kampala University in Uganda, East Africa, spent his life educating anyone who would listen about the importance of breast-feeding, particularly in developing countries. It seems like a no-brainer: Breast milk is free, readily available and sterile and helps to protect the infant from infections. Dr. Jelliffe's drumbeat of breast is best has been heard and breast-feeding is now the norm in nearly all developing countries. Breast-feeding " the longer the better " is crucial for infant survival in these countries. That was accepted wisdom, at least until a few years ago.

Accra, Ghana, 1972 The importance of breast-feeding was strikingly reinforced during my first visit to Africa to study issues of malnutrition in children. The setting for our team of pediatricians, nutritionists and immunologists was Princess Marie Louise Hospital for malnourished children, a modest, two-story, cement-block building with a corrugated iron roof, surrounded by a dusty courtyard with a single tree.

On our first morning there, we threaded our way through throngs of mothers and infants waiting to see the single Ghanaian doctor in the first-floor clinic. He examined each infant quickly, passed out medicines for the sick babies or sent the well babies to the immunization station. All the while he cast a keen eye for the swollen legs, protuberant abdomen and reddish tinge of the hair, which are the telltale signs of early kwashiorkor, the dreaded African disease of protein malnutrition. Kwashiorkor is a West African word that means "the disease that occurs when the next baby comes." It typically occurs when babies are between 1 and 2 years old, two to three months after the mother weans the infant so she can breast-feed her new baby. The weaning food is kasava, which tastes and looks like milk but is almost completely devoid of protein. So while the baby grows, the immune system weakens. Kwashiorkor is curable if recognized early, but in advanced cases diarrhea, measles or pneumonia can lead to rapid death. In the afternoon the Ghanaian doctor looked after the hospitalized, malnourished children, treating them for parasites, malaria, anemia and infections and starting them on protein feedings, usually a thin stew of nuts and rice. Our task was to pinpoint the immunologic defects in these children; what we learned was that their immune defects could be as severe as those found in David, the so-called "boy in the bubble" who was born without an immune system. But, we determined, all these immunological problems could be prevented simply by breast-feeding. I was a convert: Breast is best.

Los Angeles, May 1986 Late one spring afternoon, 14 years after my first trip to Ghana, my UCLA colleague, Dr. Richard Fine, asked me what I thought of a 4-year-old girl with kidney disease, anemia and persistent thrush of her mouth. I responded that I thought she had a severe problem with her immune system. I examined the little girl, Ariel, and confirmed the presence of thrush. And I learned that she had been perfectly well for the first few years of her life, indicating that she did not have a congenital deficiency of her immune system. I asked her mother, Elizabeth Glaser, the wife of actor Paul Michael Glaser, if Ariel had ever had a blood transfusion pediatric AIDS had recently been identified in children who were transfused at birth. She said that Ariel had not.

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