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Premastication of Food by Caregivers of HIV-Exposed Children --- Nine U.S. Sites, 2009--2010

Premastication (i.e., chewing foods or medicines before feeding to a child) was reported recently as a route of human immunodeficiency (HIV) transmission through blood in saliva (1) and has been associated with transmission of other pathogens (2--7). Approximately 14% of caregivers in the United States report premastication (8); however, the frequency of this behavior among HIV-infected caregivers is unknown. To assess the prevalence of premastication among caregivers of children being treated in pediatric HIV clinics, which include perinatally HIV-exposed children (i.e., HIV-uninfected and HIV-infected children born to an HIV-infected mother), CDC conducted a cross-sectional survey at nine such clinics in the United States during December 2009--February 2010. This report describes the results of that survey, which indicated that among primary caregivers of children aged ≥6 months, 48 (31%) of 154 reported the children received premasticated food from themselves or someone else. Approximately 37% of black caregivers reported premastication, compared with 20% of non-black caregivers (prevalence ratio [PR] = 1.8). Premastication decreased with caregiver age and was used to feed children aged 1--36 months. Public health officials and health-care providers should educate the public about the risk for disease transmission via premastication and advise HIV-infected caregivers against the practice.

Pediatric HIV clinics with which the CDC had collaborated previously in premastication-related or longitudinal, HIV-related epidemiologic studies participated in this investigation. These clinics were located in Atlanta, Georgia; Dallas, Texas; Houston, Texas; Memphis, Tennessee; Miami, Florida; New Orleans, Louisiana; Newark, New Jersey; San Juan, Puerto Rico; and the District of Columbia. A 10-minute, self-administered paper questionnaire was distributed to primary caregivers during their child's clinic visit. A primary caregiver was defined as the person responsible for feeding, clothing, and housing the child. One survey per child with an appointment was allowed; therefore, multiple interviews were possible if a caregiver had multiple children with appointments. After completion of the survey, caregivers were provided written information and counseled about the risk for disease transmission through premastication. Of 203 primary caregivers approached, 192 (95%) were surveyed (11 declined participation).

Of the 192 primary caregivers surveyed, the majority were biologic mothers of the children (81%) and U.S.-born (86%). Approximately 66% of caregivers were non-Hispanic black, 24% were Hispanic, and 7% were non-Hispanic white. The median age was 31 years for primary caregivers (range: 15--77 years) and 2 years for children (range: <1--18 years). Approximately 30% of caregivers had less than a high school education, and 49% had an annual household income of less than $12,000.

Given the decreased likelihood that children are fed solid foods during the first months of life, CDC limited its analysis to caregivers of children who were aged ≥6 months at the time of investigation (155 [81%] of 192). Among primary caregivers of these children, 44 (29%) of 153 reported ever premasticating food for the child. Fourteen (10%) of 140 primary caregivers reported that someone else had given premasticated food to the child. Overall, 48 (31%) of 154 primary caregivers stated that they or someone else had premasticated food for the child, with biologic mothers representing 79% of premasticators. Black caregivers more frequently reported ever premasticating food, compared with non-blacks (37% versus 20%, respectively; PR = 1.8) (Table 1). Premastication decreased with increasing caregiver age at interview. Caregivers aged ≤19 years were significantly more likely to premasticate than those aged ≥40 years (44% versus 13%, respectively; PR = 3.5), as were those aged 20--29 years (38% versus 13%, respectively; PR = 2.9) and those aged 30--39 years (36% versus 13%, respectively; PR = 2.8). Similar prevalences of premastication were found regardless of the sex of the child and the primary caregiver's country of origin, education level, and income (Table 1).

Primary caregivers started premastication of food for children as young as age 1 month (median age: 7 months) and stopped premastication as late as age 36 months (median age: 13 months). Among 38 premasticating primary caregivers who described frequency of the behavior, 15 (39%) reported premasticating 1--3 days in a typical week, 14 (36%) reported 4 or more days, and nine (24%) reported less than once a week. The most commonly reported reasons for premastication, reported from a predetermined list, were "child wanting some of the caregiver's food" (64%), "caregiver not wanting the child to choke" (62%), and "prechewing is done in my family" (31%) (Table 2). Meat and fish (80%) and fruit (39%) were the most commonly reported food types premasticated by caregivers.

Reported by

N Rakhmanina, MD, Children's National Medical Center; S Hader, MD, A Denson, Dept of Health, Washington, DC. A Gaur, MD, St. Jude Children's Research Hospital, Memphis, Tennessee. C Mitchell, MD, Miller School of Medicine, Univ of Miami. S Henderson, MD, Emory Univ, Atlanta, Georgia. M Paul, MD, Baylor College of Medicine, Texas Children's Hospital, Houston; T Barton, MD, Southwestern Medical Center, Dallas, Texas. M Herbert-Grant, MD, University Hospital, New Jersey Medical School. E Perez, Univ of Puerto Rico. J Malachowski, Tulane Univ School of Public Health, New Orleans, Louisiana. K Dominguez, MD, S Danner, S Nesheim, MD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; W Ivy, PhD, D Iuliano, PhD, EIS officers, CDC.

Editorial Note

In 2007, an estimated 13% of 159 diagnoses of HIV and acquired immunodeficiency syndrome (AIDS) among children aged <13 years were attributed to modes other than perinatal transmission, including hemophilia, blood transfusion, and risk factors not reported or identified.* In 2008, a case series of three pediatric HIV cases concluded that premastication was the likely mode of transmission for these children, a route not reported previously (1). Bleeding gums at the time of premastication were reported in caregivers of two of the three children in the case series. The third caregiver could not recall her dental condition at the time of premastication. One of these transmissions was to a child whose mother was not HIV-infected. HIV transmission via premastication is presumed to require blood in the mouth of the caregiver. No evidence suggests that saliva alone can transmit HIV.

In addition to HIV, transmission of hepatitis B virus (3) and group A streptococcus (6) by premastication has been documented. Furthermore, premastication has been found to be associated with increased risk for infection with Helicobacter pylori (7), Streptococcus mutans (2), human herpesvirus 8 (4), and Epstein Barr virus (5). Only one study has indicated that premastication can be associated with decreased risk for infection; that study involved respiratory syncytial virus in Alaska Native infants aged <6 months (9).

The prevalence of premastication observed in this investigation is particularly important because most of the caregivers and premasticators were biologic mothers; thus, most caregivers were HIV-infected, posing a potential risk for HIV transmission to children in their care who are uninfected. Furthermore, the higher prevalence of premastication among black and younger caregivers suggests the need for targeted prevention messages for these populations.

The reasons given by caregivers for premastication might suggest that the practice is mostly situational or in response to immediate circumstances, as opposed to reasons that reflect an inability to provide baby food or formula. Therefore, prevention messages might be effective among this population, particularly those with situational reasons for premastication. Qualitative research on premastication might be helpful to explore the reasons for premastication and to determine helpful, realistic alternatives for HIV-infected caregivers.

The findings in this report are subject to at least three limitations. First, gathering HIV status information on caregivers was not possible because surveys were completed in a setting where caregivers were accompanied by their children and other family members, some of whom might have been unaware of their caregiver's HIV status. However, given that all caregivers were surveyed in pediatric HIV clinics and 81% of primary caregivers were biologic mothers, the majority of the caregivers surveyed likely were HIV-infected. Second, the surveyed caregivers were asked to recall behaviors that might have taken place several years before survey administration; therefore, these data might be affected by recall bias. Finally, this cross-sectional investigation included a convenience sample of caregivers of children seen in HIV clinics and is not generalizable to all HIV-infected caregivers.

Although research on the risk for HIV transmission via premastication is limited, CDC recommends that HIV-infected caregivers not premasticate food for HIV-uninfected children because of the possibility of transmitting HIV to the child. Public health officials and health-care providers should continue to educate the public about the risk for disease transmission, including HIV, via premastication.


  1. Gaur AH, Dominguez KL, Kalish ML, et al. Practice of feeding premasticated food to infants: a potential risk factor for HIV transmission. Pediatrics 2009;124:658--66.
  2. Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatr Dent 2007;29:16--22.
  3. Huang MJ. An epidemiological study on prevalence and risk factors of hepatitis B virus (HBV) infection in preschool children [Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi 1990;11:129--32.
  4. Mbulaiteye SM, Pfeiffer RM, Whitby D, Brubaker GR, Shao J, Biggar RJ. Human herpesvirus 8 infection within families in rural Tanzania. J Infect Dis 2003;187:1780--5.
  5. Mbulaiteye SM, Walters M, Engels EA, et al. High levels of Epstein-Barr virus DNA in saliva and peripheral blood from Ugandan mother-child pairs. J Infect Dis 2006;193:422--6.
  6. Steinkuller JS, Chan K, Rinehouse SE. Prechewing of food by adults and streptococcal pharyngitis in infants. J Pediatr 1992;120(4 Pt 1):563--4.
  7. Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991;13:42--59.
  8. Fein SB, Labiner-Wolfe J, Scanlon KS, Grummer-Strawn LM. Selected complementary feeding practices and their association with maternal education. Pediatrics 2008;122(Suppl 2):S91--7.
  9. Bulkow LR, Singleton RJ, Karron RA, Harrison LH. Risk factors for severe respiratory syncytial virus infection among Alaska native children. Pediatrics 2002;109:210--6.

What is already known on this topic?

Premastication (i.e., prechewing) of food is a risk factor for human immunodeficiency virus (HIV) transmission to children.

What is added by this report?

This is the first epidemiologic study to investigate the prevalence of and reasons for premastication of food by caregivers of HIV-exposed children in various geographic regions of the United States. In a convenience sample of 154 primary caregivers, 31% of HIV-exposed children aged ≥6 months received premasticated food from a caregiver; younger caregivers reporting significantly higher rates of this practice compared with older caregivers, and black caregivers reported premastication more frequently than non-black caregivers.

What are the implications for public health practice?

Understanding that premastication is a common behavior, particularly among certain racial/ethnic populations, public health officials and health-care providers should educate the public about the potential risk for disease transmission, including HIV, via premastication.

TABLE 1. Prevalence of premastication of food for HIV-exposed children* aged ≥6 months, by selected characteristics --- nine U.S. sites, December 2009--February 2010




Prevalence ratio

95% CI



Sex of child













Race of caregiver













Education of caregiver

Less than high school diploma






High school diploma or higher






Annual household income of caregiver













Age of caregiver (yrs)

























Country of origin of caregiver













Abbreviations: HIV = human immunodeficiency virus; CI = confidence interval.

* HIV-uninfected and HIV-infected children born to an HIV-infected mother.

Pediatric clinics in Atlanta, Georgia; New Orleans, Louisiana; Newark, New Jersey; Memphis, Tennessee; Miami, Florida; Dallas, Texas; Houston, Texas; San Juan, Puerto Rico; and the District of Columbia.

TABLE 2. Reasons given by primary caregivers for premastication of food for HIV-exposed children* aged ≥6 months (N = 45) --- nine U.S. sites, December 2009--February 2010




Child wanted some of the food



Did not want child to choke



Prechewing is done in my family



Heard about prechewing



Away from home with no baby food



Did not have store-bought baby food



Did not make baby food



Abbreviation: HIV = human immunodeficiency virus.

*HIV-uninfected and HIV-infected children born to an HIV-infected mother.

Pediatric clinics in Atlanta, Georgia; New Orleans, Louisiana; Newark, New Jersey; Memphis, Tennessee; Miami, Florida; Dallas, Texas; Houston, Texas; San Juan, Puerto Rico; and the District of Columbia.

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