Dear Tarig You highlight a real - and one of the many - challenges of managing acute malnutrition in infants under six months. As you reflect, there is a balancing act of risks and benefits of different feeding options for caregivers and staff supporting them, not just for immediate outcomes but to longer term health and survival. ENN has partnered with the Centre for International Health and Development UCL London and Action Contre la Faim on the MAMI (Management of Acute Malnutrition in Infants) Project, that is a review of current practices and challenges in management of this age group. Implemented over 18 months, the final report is being reviewed and should be ready by the end of the month. Once available, I'll post a message and link on en-net. You can get more information on www.ennonline.net/research including the contact details for the lead researcher, that you can also contact directly. Finally, to emphasise, irrespective of the HIV prevalence of the population, if there is no individual voluntary and confidential counselling and testing available to mothers, then exclusive and continued breastfeeding is advised by WHO - as per the recommendations for the general population. A mother shouldn't be counselled to stop breastfeeding on the basis of HIV prevalence in the general population. The current WHO recommendations on infant feeding and HIV are available at: http://www.ennonline.net/resources/view.aspx?resid=696 Another useful document is the UNHCR infant feeding and HIV guidance (update due within weeks), see: http://www.ennonline.net/resources/view.aspx?resid=622

Hi Tarig As Marie points out, there is not much research in this area and you have asked a really important questions. (I am eagerly awaiting the MAMI report too.) It is worth considering also that even where mothers' HIV status is known to be positive, securing ARV therapy for the mother and supporting breastfeeding offers babies the best chance of HIV free survival in most places. Firstly, I would want to talk to mothers to try to ascertain how an infant less than six months old has become malnourished. If it is simply about infrequent feeding (due to mother's livelihood or other committments) then it maybe that simple frequent breastfeeding alone will result in improvement in the baby's nutritional status. If it is the result of inefficient milk removal then I would want to address that issue (is the baby tongue-tied? cleft palate?). Or could the baby actually be thriving but have been born SGA or prematurely or both? In which case improving mothers' nutritional status to improve the nutritional status of future infants would be a priority. If the mother has been mixed feeding already, then there may be a possibility that she is pregnant. (Pregnancy can but does not always result in a drop in milk synthesis.) For infants who do need supplementation in order to become strong enough to feed effectively, I wonder if you have considered using human milk in place of dilute F100 for at-breast supplementation? This could either be mothers' own milk (MOM) or flash pastuerised donor milk. I don't believe there is published research looking at the effect of the use of MOM or pasteurised donor milk in at-breast supplementation for infants suffering SAM on HIV-free survival rates but it makes sense biologically since the mechanism of increased MTCT appears to be associated with damage to the gut caused by the introduction of non-human milk. The advantage of using MOM is that removing more milk from the breast will increase the mothers' milk production more quickly than supplementation using artificial milk. Mothers would have to be taught hand expression but this is not difficult (google Marmet Technique). If you do try using human milk for at-breast supplementation, be sure to document both the method you use and the HIV free survival rates if you can and publish the results. Cheers Nina