Treatment of severe acute malnutrition in HIV-infected children
Biological, behavioural and contextual rationale
In children aged 6–60 months, WHO defines severe acute malnutrition (SAM) as a weight-for-height of less than -3 standard deviations of the WHO standards, or a mid-upper arm circumference of less than 115 mm, and/or the presence of bilateral oedema (swelling of both feet). Severe acute malnutrition affects about 20 million children under the age of five and is associated with 1–2 million preventable deaths every year 1. Children with severe acute malnutrition have an elevated (nine times) risk of death compared with normal or moderately malnourished children 1. In most developing countries case fatality rates remain high at about 20–60% 2 .
Children with complicated severe malnutrition (those with poor appetite, fever, pneumonia, dehydration, severe oedema or infants aged less than six months) are managed in inpatient facilities until complications are resolved, using the WHO 10 steps to management of severe acute malnutrition 3. These steps are divided into two phases: stabilization and rehabilitation.
Stabilization aims to reduce oedema and restore tissue and organ function. It involves treating infections and other medical problems, providing sufficient energy and nutrients to stop further loss of muscle and fat, and correcting electrolyte imbalance using the formula diet F-75 that contains 75 kilocalories and 0.9 grams of protein per 100 millilitres.
During rehabilitation children are provided with extra energy and nutrients for rapid weight gain and catch up growth. F-100, another formula containing 100 kcal and 3 g of protein per 100 ml is recommended in this phase. Children are also provided mental stimulation through play sessions to improve cognitive development, and carers are supported to prevent recurrence of malnutrition.
Children with uncomplicated severe malnutrition (those with appetite, and who are clinically well and alert) can be managed in the community or as outpatients using ready-to-use therapeutic food (RUTF). RUTF was developed as an energy-dense micronutrient-fortified food with properties similar to F-100 4; it does not require cooking, has a low moisture content hence a long shelf life, and does not require supervised feeding. This approach also addresses lack of access, coverage and timely treatment associated with the traditional inpatient model. It has been widely shown to achieve good levels of nutritional recovery, to reduce mortality, and to shorten the duration of inpatient treatment for children with severe acute malnutrition 5–7. Integrating these two arms of treatment allows referral of complicated cases presented in the community to treatment centres for stabilization and subsequent discharge of children for rehabilitation in communities once complications are resolved 8,9.
Globally, 2.1 million of the 33 million people living with HIV/AIDS are children 10. HIV infection has increased the prevalence of severe acute malnutrition 11 and vice versa. HIV can lead to poor nutrition as result of poor food intake, increased nutrient usage, loss of nutrients from the body and other metabolic derangements 12. In a recent review, more than 30% of severely malnourished children in sub-Saharan Africa admitted to inpatient nutrition rehabilitation units were HIV-infected 2. HIV-infected children with severe acute malnutrition were three times more likely to die compared with uninfected children 2. The infected group had persistent diarrhoea, pneumonia, extensive skin infections and oral thrush, which contributed to higher case fatalities and poorer response to management 11, 13-16
The majority of these HIV infected children were not on antiretroviral therapy (ART) and CD4 levels were not assessed 2. In the absence of CD4 assessment, the clinical stage of HIV infection should form the basis to decide when to start antiretroviral therapy 17. Most HIV-infected children with severe acute malnutrition require antiretroviral therapy because they normally present with advanced HIV disease. However, these children have increased risk of death and non-compliance to antiretroviral therapy due to severe malnutrition. HIV-infected children can achieve an adequate weight-for-height with appropriate therapeutic feeding 18,19, although recovery times were significantly longer in the infected children 2. By providing antiretroviral therapy to manage the viral infection coupled with adequate therapeutic feeding, it is possible to reduce mortality among children with both HIV and severe acute malnutrition. Further studies are recommended to assess the impact of antiretroviral therapy on nutritional recovery in HIV-infected children with severe acute malnutrition.
1 WHO child growth standards and identification of severe acute malnutrition in infants and young children. A joint statement by WHO and UNICEF, 2009.
2 Fergusson P, Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2009, 103(6):541–8.
3 Management of severe acute malnutrition: manual for physicians and other health workers. Geneva, World Health Organization, 1999.
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6 Collins S, et al. Management of severe acute malnutrition in children. The Lancet, 2006, 368(9551):1992–2000.
7 Collins S, et al. Key issues in the success of community-based management of severe malnutrition. Food and Nutrition Bulletin, 2006, 27(Suppl. 3):S49–82.
8 Community-based management of severe acute malnutrition. A joint statement by WHO, WFP, SCN and UNICEF, 2007.
9 Prudhon C et al. WHO, UNICEF and SCN informal consultation on community-based management of severe malnutrition in children. Food and Nutrition Bulletin, 2006, 27(3) (supplement, SCN Nutrition Policy Paper No. 21).
10 UNAIDS report on the global AIDS epidemic. Geneva, UNAIDS, 2010.
11 Amadi B et al. Intestinal and systemic infection, HIV, and mortality in Zambian children with persistent diarrhea and malnutrition. Journal of Pediatric Gastroenterology and Nutrition, 2001, 32(5):550–4.
12 Semba R, Tang A. Micronutrients and the pathogenesis of human immunodeficiency virus infection. British Journal of Nutrition, 1999, 81(03):181–9.
13 Bachou H et al. Severe malnutrition with and without HIV-1 infection in hospitalised children in Kampala, Uganda: differences in clinical features, haematological findings and CD4+ cell counts. Nutrition Journal, 2006, 5:27.
14 Kessler L et al. The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi. Annals of Tropical Paediatrics, 2000, 20(1):50–6.
15 Bachou H et al. Risk factors in hospital deaths in severely malnourished children in Kampala, Uganda. BMC Pediatrics, 2006, 6:7.
16 Chinkhumba J et al. The impact of HIV on mortality during in-patient rehabilitation of severely malnourished children in Malawi. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2008, 102(7):639–44.
17 Antiretroviral therapy for HIV infection in infants and children: towards universal access. Recommendations for a public health approach, 2010 revision. Geneva, World Health Organization, 2010.
18 Bahwere P et al. Uptake of HIV testing and outcomes within a community-based therapeutic care (CTC) programme to treat severe acute malnutrition in Malawi: a descriptive study. BMC Infectious Diseases, 2008, 8:106.
19 Fergusson P et al. Nutritional recovery in HIV-infected and HIV-uninfected children with severe acute malnutrition. Archives of the Diseases of Childhood, 2009, 94(7):512–6.
The named authors alone are responsible for the views expressed in this document.
Declarations of interests
Conflict of interest statements were collected from all named authors and no conflicts were identified.