HIV & Nutrition

Nutrition In Pediatric HIV Infection

Written exclusively for HIVpositive.us by:
Melissa Zafonte, RD, Clinical Research Dietitian, Warren Grant Magnuson Clinical Center, National Institutes of Health

   Malnutrition
   Reasons for Malnutrition
   Nutritional Assessment and Support of the HIV Positive Child
   Estimating Energy Needs
   Suggested Interventions for Nutritional Problems
   Diarrhea/Malabsorption
   A Note About Drinking Water
   The Importance Of Finding A Dietitian

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Malnutrition:

Malnutrition is a common complication of HIV infection and AIDS. Malnutrition places added stress on an already weakened immune system and may complicate the treatment of the disease by affecting the intestinal tracts ability to absorb drugs, not to mention its inability to absorb proteins, carbohydrates and fats.

Malnutrition in children is particularly devastating because children are still growing and developing, placing even higher energy demands on their bodies and immune systems. All children, regardless of the stage of their infection, should be seen by a registered dietitian (RD) for a thorough assessment and evaluation. It has been estimated that over 90% of children with HIV infection/AIDS will experience delayed growth. The reason for this is multifactorial including poor socioeconomic situations, poor nutritional intake, malabsorbtion and the disease itself.

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Reasons for Malnutrition:

Changes in Metabolism

alterations in the function of the gastrointestinal tract and the ability to use food in an efficient way
increased use of body fat stores
recurrent fevers and infections causing a rise in metabolic rates
depletion of vitamin and mineral stores

Changes in Oral Intake

decreased intake due to medication schedules that require the child to be without food (NPO) for a period of time before and after the medications are given, as well as potential problems with nausea, vomiting and mouth sores
altered intake due to oral infection with Candida (thrush.) Bear in mind that Candida can invade the esophagus (throat), as well as the small intestine without being present in the mouth
lack of adequate food supply in the home
caregivers that may be infected as well and not able to care for the child properly
inability to tolerate fats and lactose (milk sugars)
diarrhea, the cause of which may or may not be known

Functional Impairment

chewing and swallowing may be greatly affected in children with HIV involvement of the nervous system. An evaluation by a speech pathologist can be very beneficial.

Nutritional Assessment and Support of the HIV Positive Child

Assessment:

Detailed diet history: to include food frequency and/or 24 hour recall. Pay special attention to food intolerances, feeding skills and developmental milestones as well as any nutritional supplements (liquid products used to increase calorie intake.) This will allow the practitioner to determine any nutrient deficiencies or areas of the diet that can be improved to insure adequate provision of calories, protein, vitamins, and minerals. A Registered Dietitian should be consulted to do the interview and analyze the results and then help the family in developing more appropriate eating plans.
A medication history: to include antiretrovirals, any medications for opportunistic infection treatment, use of /vitamins, minerals, and alternative therapies such as herbs. This will allow the practitioner to evaluate any drug-nutrient interactions that the family should be counseled on (i.e. ddI needs to be taken on an empty stomach; or avoiding Iron supplements with dairy products) and to see if the type and number of medications the child is taking may be contributing to poor nutritional intake.
Anthropometric data- height, weight, height-for-age, weight-for-age, weight-for-height, and head circumference in children up to 7 years of age. Keeping track of anthropometric data allows the practitioner the ability to evaluate the child over time, not just singular examination, when trying to make treatment decisions. Medications may need to be recalculated based on weight and height changes because the body surface area has changed.
It is also mandatory for the pediatric practitioner to get as detailed a history as possible on growth trends in the past. It is often quite easy to tell from a good growth chart when children have had infections or periods of stress.
Midarm circumferences and triceps skinfolds should be done every six months as well. This will help in longitudinal tracking of patients. Tracking these measures may indicate to the practitioner subtle changes in fat stores or lean body mass changes prior to actually seeing changes in the patient.
It is important to remember that with new technologies arising there are ways of measuring resting energy expenditure (Metabolic Carts) and body composition (Bioelectric Impedance Analysis). These technologies are not always available and can be expensive and results are influenced by multiple factors. A trained practitioner needs to do the testing and interpretation of results.
Evaluation of weight changes. The definition for AIDS Wasting Syndrome is 10% body weight loss. It is crucial to remember in pediatric patients, that this can amount to as little as a 1 kilogram (kg) weight loss. As soon as weight loss, for any reason, is noted, a full assessment should be done. Remember that the downward slope for weight loss is a slippery one and can be hard to reverse in small children.
Laboratory Data: (check the availability in your institution) Keep in mind that normal laboratory values may differ from place to place. The following is a list of lab tests that could be beneficial for the nutritional assessment of a patient.
- Albumin and Prealbumin
- Transferrin/Total Fe and % saturation
- B12/Folate
- CBC with Differential
- Electrolytes
- Liver and Renal Functions

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Estimating Energy Needs

There is a paucity of data published on the energy needs of children infected with HIV. Some studies have suggested that energy needs can be as elevated as 50% above baseline and some studies have shown no effect on energy expenditure. One thing is for certain, these children need more calories and protein on a per kilogram basis than their healthy counterparts do.

There are a number of ways to calculate energy needs. If you are fortunate enough to have access to a Metabolic Cart this is a wonderful technology to use. The cart will produce an expected or predicted energy expenditure and an actual measured expenditure. The cart will then calculate the difference in these measurements, determining if the child is hypometabolic or hypermetabolic.

Two of the more standard ways to calculate nutritional needs are either with the Recommended Daily Allowance (RDA) tables, using a calorie/kilogram (kcal/kg) method, or the Bentler and Stannish formula for catch-up growth. If a child is very small for its age, the kcal/kg will be based on the weight-age of the child. It is not uncommon for some children to require as many as 200 kcal/kg and up to 4 grams/protein/kilogram (gr/pro/kg).

In an ideal world the practitioner would have access to multiple assessment tools and be able to compare the results to determine what is best for the child. The use of tracking sheets and growth curves can prove very beneficial. Parents should be encouraged to keep track of their child's growth as well.

Keep the calorie recommendations realistic. Growth is not always the primary outcome, especially during periods of stress or opportunistic infections. Weight maintenance may be the best to hope for during these times. After the acute period of stress or infection is over, it is important to start building the child up again nutritionally.

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Suggested Interventions for Nutritional Problems

Poor Oral Intake:

A frequently used and tolerated intervention is to encourage small, frequent feedings instead of a traditional three (3) meal pattern. Parents and caregivers may feel that unless the child is eating three (3) meals they are not getting adequate nutrition. It is important to remember that if smaller meals and snacks are planned appropriately. sufficient calories and protein can be provided.

Infants may require having their formulas concentrated to 24, 26 or even 30 calories per ounce. It will be imperative to teach parents how much free water the child needs to have as well. Formulas can also be boosted with medical nutritionals such as carbohydrate sources (Polycose^®), protein sources (Promod^®, Meritene^®), or fat sources (Microlipid^®). If parents are going to use vegetable oil for boosting calories, it is important to keep shaking the bottle gently during the feeding. (Vegetable oil will rise to the top of the formula. If the infant receives the oil in this concentrated form, it may cause diarrhea.)

Other supplements available for older children greater than 8-10 years of age, include Pediasure^®, Instant Breakfast type drinks, Resource^®, and Scandishake^®. These are available at your pharmacy or grocery store.

The old standby's of adding margarine and butter and dried milk powder are also good to use as well. I encourage the use of pediatric formulas as much as possible for my clients that are under 10 years of age.

It is common practice at the Clinical Center to recommend vitamin and mineral supplements for all children, regardless of the stage of infection. One that provides 100% of the RDA for the age range of the child is appropriate. For older children and adolescents an adult vitamin is appropriate.

Oral Lesions:

Foods and fluids should be served as close to room temperature as possible to reduce heat intolerance. Fluids may be better tolerated through a straw. Non-acidic beverages are better tolerated. Supplements will be very beneficial in this instance as they can provide good sources of all nutrients in small volumes.

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Diarrhea/Malabsorption:
As always, it is crucial to determinet the underlying cause of the diarrhea and if possible, have it medically treated.
If the symptoms come from infectious causes, supplemental feedings via tube feedings and or Total Parenteral Nutrition may be indicated on a short term basis. There are specific formulas available on the market that may be better tolerated. Most tube feedings are lactose-free, but some also have modified forms of fat such as Lipisorb^®. Others are elemental and easily digested such as Vivonex Pediatric^® and Peptamen Junior^®. The dietitian, case manager and physician should all have suggestions as to what type of formula is appropriate, and the best means of delivering the formula to the patient.
For acute periods of diarrhea it may be necessary to limit the amount of lactose and fat in the diet:
1. Offer lactaid milk and yogurt products.
2. Soy milk may be offered.
3. Offer small frequent meals.
4. Try to include soluble forms of fiber in the diet (i.e. oatmeal; rice; bananas; applesauce.)
5. Replace fluid losses with electrolyte solutions such as Peidialyte^® or Ricelyte^®.
Potassium and sodium are two electrolytes, in particular, that may need added replacement. For sodium: try foods such as broths, bouillon, and crackers. For potassium: foods such as bananas, apricots, potatoes, and meats (prepared plainly).
There may be other approaches that are not discussed here, please consult with your dietitian. The case manager can provide a referral to a dietitian. A dietitian can help personalize a plan just for your child to make sure they are getting all the nutrition they need.
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A Note About Drinking Water
In certain parts of the country recently, there has been an increased occurrence of a water-born illness known as Cryptosporidiosis. The organism Cryptosporidium is found in wells, lakes, rivers, and in some water supplies. People with depressed immune systems, especially those with CD4 counts less than 200, are at increased risk of infection from this organism. The symptoms of Crytopsporidiosis include large amounts of watery diarrhea. For children this is a potentially life threatening situation if they become too dehydrated.
Bottled waters are okay, but not all manufacturers have safeguards in place to be sure that Cryptosporidium is not present. To be on the safe side boil water for 30 minutes then place in containers to be used when needed. If children are going to be swimming in lakes, pools etc., it is important that they not swallow any water.

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The Importance Of Finding A Dietitian
Everyone infected with HIV should see a dietitian as soon as possible after diagnosis and at intervals determined to be appropriate based on needs.
It is especially important that children be followed by a dietitian as part of the medical team to be sure that oral intake is adequate to support growth and development.
If your child's case worker or primary physician cannot recommend a dietitian in your area you can find a dietitian right now, or contact the American Dietitic Association web site or call the ADA toll free at 1-800-336-1655 to get the name of someone close to your area.
More information about "How to Find a Registered Dietitian" from the American Dietitic Association is available on this web site.

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