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To the Editor: Dr Miotti and colleagues1 found a significant decrease in the risk of human immunodeficiency virus (HIV) transmission to infants after 6 months of breastfeeding in Malawi. However, some limitations may have weakened their conclusions.
Whereas the main inclusion criterion was a negative polymerase chain reaction (PCR) result for HIV at 6 weeks of life, more than 25% of the children had tested negatively earlier (lower quartile, 1.4 months). For the many cases estimated to have occurred before 3 months of life (Figure 2, in their article), the first negative PCR result was probably obtained very early, at a minimum of 0.7 months, and the first positive PCR result shortly after. Even by using dried blood spot,2 timing of acquisition of HIV infection cannot be ascertained for these children, who were nevertheless considered as cases of postnatal transmission in the analysis. The authors' assumption of underestimation of postnatal transmission during the first semester of life seems therefore unlikely.
No information about the distribution of time intervals between the last negative and the first positive PCR result was provided. These data would have been useful to assess the precision of the estimated date of infection. The circumstances of follow-up may have introduced imprecision in the estimations, especially after 12 months of follow-up.3 Moreover, the authors' Figure 3 suggests a substantial decrease in infection rate after the first year of life rather than after the first 6 months as stated in the text.
The hypothesized relationship between birth weight and quantity of ingested milk can be decreased by the probable increased maturity of intestinal tract and immunological status of the heaviest infants. Also, the relationship suggested by the authors between mastitis and maternal age has not been observed in a comparable population.4 More precise data on breastfeeding practices (exclusive or mixed) would have been useful, especially given the findings of recent publications.5
Finally, Miotti et al provided interesting information on the risk of HIV transmission through breastfeeding, but their conclusions about the implications of these findings should be moderated. Consequences of artificial feeding and early weaning on infant growth and morbidity are poorly understood. We hope that current studies and pilot programs of reduction of mother-to-child transmission of HIV in Africa will soon provide such data to complement risk estimations of postnatal HIV transmission.6
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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