Formula-Feeding of HIV-Exposed Uninfected African Children Is Associated with Faster Growth in Length during the First 6 Months of Life in the Kesho Bora Study

Abstract

Background: Early feeding patterns may affect the growth of HIV-exposed children and thus their subsequent health and cognition.Objective: We assessed the association of infant feeding (IF) mode with length-for-age z score (LAZ) and stunting from age 2 d to 18 mo in HIV-exposed African children within a controlled randomized trial, which evaluated triple antiretrovirals initiated during pregnancy and continued for 6 mo postpartum to prevent HIV transmission.Methods: HIV-infected pregnant women with CD4⁺ counts of 200-500 cells/mm³ from Burkina Faso, Kenya, and South Africa were advised to exclusively breastfeed for up to 6 mo or to formula-feed from birth. Factors associated with LAZ were investigated in all uninfected children by using mixed-effects linear models; those associated with stunting (LAZ <-2) at 6 or 12 mo were assessed in multiple logistic regression after exclusion of children stunted at age 2 d. Independent variables were IF mode: formula feeding (FF), exclusive breastfeeding (EBF) <3 mo, or EBF ≥3 mo (reference); sex; trial arm; maternal characteristics; and site.Results: Among 728 children, FF was associated with a greater increase in LAZ from 2 d to 6 mo (+0.07 z score/mo, P < 0.001). Between 6 and 18 mo, FF and EBF <3 mo were both associated with greater mean LAZ than was EBF ≥3 mo (+0.52 z scores and +0.43 z scores, respectively, P < 0.001). Among children not stunted at 2 d, FF was independently associated with a reduced risk of stunting at 6 mo (OR: 0.24; 95% CI: 0.07, 0.81; P = 0.021), whereas EBF <3 mo was not (OR: 0.49; 95% CI: 0.22, 1.10; P = 0.09).Conclusions: In this observational study of HIV-exposed uninfected infants, growth in length in the first 6 mo of life was faster in formula-fed infants than in exclusively breastfed infants. The plausibility of residual confounding and reverse causality is discussed. This trial was registered at www.controlled-trials.com as ISRCTN71468401.

Keywords: Africa; HIV infection; breastfeeding; infant growth; stunting.

FIGURE 1

Flow diagram of HIV-exposed uninfected children included in the observational cohort study of infant and young child growth within the Kesho Bora randomized clinical trial. FU, follow-up.

FIGURE 2

LAZ (A) and WLZ (B) by infant feeding mode from birth to age 18 mo in HIV-exposed uninfected children in the Kesho Bora randomized clinical trial. Values are means and 95% CIs (n = 114–311). Seven hundred twenty-eight children had ≥1 length measurement. Short EBF: <3 mo; long EBF: ≥3 mo. BF, breastfeeding; EBF, exclusive breastfeeding; LAZ, length-for-age z score; WLZ, weight-for-length z score.