Detailed medical histories of many of the infants placed in care at ITL were often unavailable due to poor socioeconomic circumstances and frequent abandonment. Recent improvements in the prevention of mother-to-child transmission by the treatment of HIV positive women has resulted in fewer infants who are HIV positive at birth. This was not the case when the community milk bank began operating. Some of the case reports date back to 2003 and 2006, but have been included as these infants were severely compromised on arrival at ITL and together with medical attention, the progress they made on DHM was marked. Given the paucity of documented case histories of exclusive DHM nutrition in a non-hospital based and older infants, their inclusion is important.
The routine medical management of HIV positive infants at ITL included screening for tuberculosis and prophylactic treatment with co-trimoxazole which was started at four to six weeks after birth and continued until they were five years of age. In addition, they received antiretroviral treatment (ARV) when it became available. In the early days of treating HIV positive children, early routine ARV treatment was not practiced. Medical management was provided by a local teaching hospital. Scabies was treated with tetmosol soap and benzyl benzoate lotion and eczema with aqueous cream and different emollients. Tuberculosis was treated with an intensive 2-month phase of rifampicin/ isoniazid, pyrazinamide with lower-dose therapy using the same agents, for a further four months.
Case 1
Baby A was born at term by caesarean section due to fetal distress. Her birthweight was 3.1 kg, length (L) 45 cm, head circumference (HC) 36 cm. The mother was HIV positive. Baby A was abandoned at six weeks, with a bag of clothing and a tin of infant formula and her birth record. Unable to trace the mother, she was placed in care and arrived at ITL on 21 September 2006 when she was eight months old. She weighed 8.18 kg, was HIV positive, Mantoux positive and negative for syphilis. Her eczema was severe, as is commonly associated with HIV positive children. She was started on DHM immediately. She was placed on treatment for tuberculosis from October 2006 until May 2007. In June 2007, her CD4 count was 18 and she was started on ARV. She had a severe dose of chicken pox and mumps at two years of age, but other than that had no repeated infections commonly associated with HIV positive children. Her milestones were appropriate for her age. She continued to receive DHM until she was three years old. The decisions were made to continue for a longer period than normal as whenever the DHM was stopped, her eczema was exacerbated. She was a happy, confident, intelligent little girl who enjoyed good health despite her medical status and ongoing treatment. She was adopted in July 2011 aged five years (Fig. 1).
Case 2
Baby B was born weighing 2.5 kg. His mother and grandmother had full blown AIDS and he was diagnosed with HIV at birth. He was found in his home neglected, as his mother was too ill to care for him and she signed him over for adoption. He arrived at ITL at 2.5 months, weighing just 3.1 kg. He was suffering from malnutrition, tuberculosis, respiratory distress and was HIV positive. In addition, he had scabies and severe eczema. DHM was started upon arrival. A month later, at 3.5 months, he began treatment for TB. Apart from drainage of a few skin abscesses at four months of age, his general condition improved on the DHM, as did his eczema and he thrived and attained all his milestones appropriately. He remained on the DHM until he was 14 months old. At the age of 21 months he was started on ARVs which increased his CD 4 count from 13 to 30% in a six month period and was adopted at this time.
Case 3
Baby C was a male born preterm. There are no records of gestation and he weighed 1,500 g. The mother was 25 years old, HIV positive and abandoned the infant in hospital where he was also diagnosed as being HIV positive. He was placed in care on co-trimoxazole (sulfamethoxazole and trimethoprim) and antiretroviral prophylaxis. He failed to thrive. At five months he was admitted to hospital critically ill. An ultrasound of his head revealed prominence of ventricle and cerebrospinal fluid space which suggested brain atrophy. Due to his poor prognosis no ARVs were recommended. He was transferred to ITL at seven months of age, weighing 2.7 kg. He was immediately started on DHM and after two weeks of exclusive DHM he had gained 550 g. In seven months of exclusive formula feeding, he had gained only 1200 g. He continued to gain weight but at eight months was transferred to a hospice for nursing care as he was too ill to be placed in foster care or to be adopted and died a short while later (Fig. 2).
Case 4
Baby D was admitted to a hospital in Durban, South Africa at two months with severe gastroenteritis, dehydration and marasmus. At approximately four months, he was still in hospital, he weighed 3.9 kg, the diarrhea had not improved and he had not gained weight in hospital despite intensive nutritional intervention. The infant was brought to ITL during a hospital workers strike, by medical officers at the hospital. He was not tolerating the specialized formula brought by the doctors, so he was offered DHM. During his two week stay there was an improvement in his condition. The diarrhea resolved, he started gaining weight, he started smiling and responding. Unfortunately, as he was not an infant placed in the care of ITL no records were kept of his weight gain during his time in our care. The two medical officers who collected him after the resolution of the strike made the following comments:
“Improvement was radical, dermatitis had resolved, gastroenteritis resolved, child was more alert and responsive, even the fisting had improved somewhat. This study was retrospective and there are poor records but if medical science can be considered both a science and an art, what breastmilk did for that baby is a masterpiece.” Medical Officers.
Case 5
Baby E was born by normal vaginal delivery at 33 weeks gestation. He was twin two, with a birthweight of 2.250 g, Apgar 6/10, 8/10, L 44 cm, and HC 33 cm. His mother was 24 years old and HIV negative. Both infants were abandoned in the care of a neighbour when they were three months old. Baby E was admitted to hospital with severe malnutrition soon after weighing 2.9 kg, with bipedal oedema and a haemoglobin count of 7.5. On 15 August 2016 at four months of age, weighing 3.5 kg, L 53 cm and HC 39 cm, he was transferred to ITL and started on DHM immediately. On examination, he was found to have low set ears, epicanthic folds and a broad nose base, so was referred for genetic testing. His weight gain from birth had been poor. After a month on DHM, he had gained 1.3 kg, the same amount he had gained in the previous four months. Good weight gain continued on DHM, with complimentary food added at six months and DHM continued until he was eight months old. His genetic testing was normal and bloods taken for HIV, syphilis and hepatitis B were all negative. Milestones were somewhat delayed, he rolled over at six months, sat at nine months started crawling at a year and at 16 months was pulling himself up and walking around furniture. He is still being cared for at ITL (Figs. 3 and 4).
Case 6
Baby F was a female born by an emergency caesarean section for fetal distress. Although term, her birthweight was 2 kg, L 47 cm, head circumference 34 cm. The mother was an HIV positive teenager. The infant was exclusively formula fed for 10 days and given nevirapine syrup as ARV prophylaxis for six weeks. She arrived at ITL on 14 August 2014 when she was 10 days old and was started on DHM immediately. All blood tests for HIV, syphilis and hepatitis B were negative. At three months, she weighed 5 kg, with L 57 cm and HC 40.5 cm. She was fed with DHM until her time of adoption at six months Figs. (Fig. 5 and 6).
Case 7
Baby G arrived at ITL in 2015 when he was one-day-old weighing 1.9 kg. His mother had concealed her pregnancy. The baby boy was fed with DHM from the day of arrival. He was switched to infant formula in November and December 2015, when supplies of DHM ran out; however, he did not tolerate the artificial substitute well and began vomiting after feeds. When DHM was available again in January 2016, his condition improved, the vomiting stopped and he gained weight once again. He was adopted at six months weighing 7.4 kg (Fig. 7).