Nutritional care for HIV-infected children
Biological, behavioural and contextual rationale
The nutritional consequences of HIV were among the first to be recognized and reported (Slims disease) in Africa. The association between HIV infection and growth faltering in children has been reported in both resource-rich and resource-poor settings. These interactions have particular relevance because of the significant geographical overlap between regions with high HIV prevalence and regions where food insecurity and moderate and severe malnutrition are also common.
Poor growth in HIV-infected children may have many causes, including:
- reduced food intake due to socioeconomic circumstances or altered caregiving practices such as when the mother is unwell
- opportunistic infections that can affect food intake, absorption and metabolism and so cause weight loss.
However, even when children are otherwise well, HIV infection itself may result in poor growth and weight gain (1). HIV-infected children who are significantly underweight are much more likely to die than HIV-infected children who are not malnourished (2).
Given the important relationship between HIV, nutrition, growth and survival of children living with HIV, it is recommended that nutritional assessment and support should be an integral part of the care plan of an HIV-infected infant or child (3). Nutritional assessment, including an evaluation of the child's growth pattern, appetite, diet (including caregiving practices and family food security) and opportunistic infections (4), can help in the early identification of growth faltering. Guidelines suggest that asymptomtic HIV-infected children may require up to 10% more energy than uninfected children, and growth should be monitored very carefully to detect any increased energy needs. Caregivers should be encouraged and counselled on the nutritional needs of growing children, the nutritional value of different foods, the avoidance of obesity and general food hygiene (3).
Adequate micronutrient intake is best achieved through a balanced diet (5). Caregivers should be counselled on the best local food choices and preparation methods to ensure micronutrient intake equivalent to one recommended daily allowance (RDA) (3). In situations where this cannot be achieved, supplementation may be necessary. However, when dietary intake is sufficient, micronutrient supplementation does not appear to have any effect on HIV progression, mortality or morbidity (6). HIV-infected children benefit from both high dose vitamin A supplementation (7,11) and the addition of zinc to oral rehydration therapy for the treatment of diarrhoea (12), as given to their uninfected peers.
If growth faltering is identified then the cause needs to be identified. During opportunistic infections, energy requirements may increase by 20–30% (5,3). In particular, diarrhoeal illnesses and tuberculosis can result in significant weight loss. Extra energy can be provided through a combination of increasing the energy density of family foods, increasing the quantity of food consumed each day and providing energy supplements. Caregivers should also be counselled on how to manage symptoms that interfere with normal eating and digestion, such as mouth sores, oral thrush and diarrhoea (3). Current recommendations suggest how to improve food intake in these situations, such as adding extra energy and protein to local foods, giving the child mashed or chopped food with sauces in the case of mouth sores, or cooked rather than raw fruits and vegetables in case of diarrhoea (3).
Severe wasting (13) is a common clinical presentation of HIV infection in children. HIV-infected children with severe malnutrition have a higher risk of mortality than uninfected malnourished children. In children experiencing growth failure (failure to gain weight, weight loss), feeding difficulties (due to oral thrush, loss of appetite) or malabsorption due to persistent diarrhoea, more targeted support may be necessary. During and following periods of severe malnutrition, energy requirements may increase by 50–100% in order to recover weight (6). HIV-infected children should follow the same treatment of severe malnutrition as uninfected children (14). It should be noted that where malnutrition is endemic, HIV-infected children may become severely malnourished because of other non-HIV related causes, including food insecurity and starvation. Initiation of antiretroviral therapy is indicated in HIV-infected infants and children with unexplained severe malnutrition that is not caused by an untreated opportunistic infection, and who do not respond to standard nutritional therapy (i.e. stage 4 disease).
1. Arpadi S, Cuff PA, Kotler DP, Wang J, Bamji M, Lange M, Pierson RN, Matthews DE. Growth velocity, fat-free mass and energy intake are inversely related to viral load in HIV-infected children. Journal of Nutrition. 2000; 130:2498–502.
2. Callens S, Shabani N, Lusiama J, Lelo P, Kitetele F, Colebunders R, et al. Mortality and associated factors after initiation of pediatric antiretroviral treatment in the Democratic Republic of the Congo. Pediatric Infectious Diseases Journal. 2009; 28:35–40.
3. WHO. Guidelines for an integrated approach to the nutritional care of HIV-infected children (6 months–14 years): handbook, chart booklet and guideline for country adaptation. Geneva: World Health Organization; 2009. (http://www.who.int/nutrition/publications/hivaids/9789241597524/en/)
4. WHO. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-forage: methods and development. Geneva: World Health Organization; 2006. (http://www.who.int/childgrowth/standards/technical_report/en/)
5. WHO. Nutrient requirements for people living with HIV/AIDS. Report of a technical consultation. Geneva, 13–15 May 2003. Geneva: World Health Organization; 2003. (http://www.who.int/nutrition/publications/hivaids/9241591196/en/)
6. Irlam J, Visser MM, Rollins NN, Siegfried N. Micronutrient supplementation in children and adults with HIV infection. Cochrane Database of Systematic Reviews. 2010;(12):CD003650.
7. WHO. Vitamin A supplements: a guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia. 2nd ed. Geneva: World Health Organization; 1997. (http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficiency/9241545062/en/)
8. Coutsoudis A, Bobat RA, Coovadia KM, Kuhn L, Tsai WY, Stein ZA. The effects of vitamin A supplementation on the morbidity of children born to HIV-infected women. American Journal of Public Health. 1995; 85:1076–81.
9. Fawzi W, Mbise RL, Hertzmark E, Fataki MR, Herrera MG, Ndossi G, Spiegelman D. A randomized trial of vitamin A supplements in relation to mortality among HIV-infected and uninfected children in Tanzania. Pediatric Infectious Diseases. 1999; 18:127–33.
10. Fawzi W, Mbise R, Spiegelman D, Fataki M, Hertzmark E, Ndossi G. Vitamin A supplements and diarrhoeal and respiratory tract infections among children in Dar es Salaam, Tanzania. Journal of Pediatrics. 2000; 137:660–7.
11. Semba R, Ndugwa C, Perry RT, Clark TD, Jackson JB, Melikian G, Tielsch J, Mmiro F. Effect of periodic vitamin A supplementation on mortality and morbidity of HIV-infected children in Uganda: a controlled clinical trial. Nutrition. 2005; 21:25–31.
12. Bobat R, Coovadia H, Stephen C, Naidoo KL, McKerrow N, Black RE, Moss WJ. Safety and efficacy of zinc supplementation for children with HIV-1 infection in South Africa: a randomised double-blind placebo-controlled trial. The Lancet. 2005; 366:1862–7.
13. Management of a child with a serious infection or malnutrition: guidelines for the care at the first-referral level in developing countries. Geneva: World Health Organization; 2000. (http://www.who.int/maternal_child_adolescent/documents/fch_cah_00_1/en/)
14. WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: World Health Organization; 1999. (http://whqlibdoc.who.int/publications/2005/9241593180.pdf)
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.