SF AIDS Fdn: BETA 7/98 -- HIV and Children: The Nutrition Story -- Part 2

Published in the Bulletin of Experimental Treatments for AIDS July 1998 issue, by the San Francisco AIDS Foundation.

HIV and Children: The Nutrition Story
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July 1998 Table of Contents

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HIV and Children: The Nutrition Story -- Part 2

By Cade Fields-Gardner, MS, RD/LD

Nutrition in Pediatric HIV Disease

Nutrition issues are complex and have long-term consequences. The hallmark of HIV disease in children is growth failure. In addition, immunologic damage and deterioration are always threatening. Practical issues abound. Decisions on the types of treatments to fight HIV and its various complications must take into account the ability of the child to adjust to and accept treatment, as well as the ability of a parent or other care provider to support the child and assure adherence to treatment.

Key studies on growth failure suggest that problems may start even before birth. The effects of HIV on the process of growth failure are not clear. However, the mother’s nutritional status is very important to the full development of the fetus prior to birth. Additional challenges after birth can include any or all of the following:

high energy needs
poor food intake
not absorbing food well from the intestines.

Researchers consistently state that early treatment and watching carefully for signs and symptoms of malnutrition are the keys to keeping growth and development on track. In fact, growth failure may be one of the first significant indications of malnutrition. Other researchers suggest that part of the problem may be metabolic, in that the processing and storage of nutrients may be altered in children with HIV. Changes in cytokine profiles, changes in anthropometric measures (e.g., height, weight, arm circumference, fat-folds) and hormonal alterations may contribute to growth failure and wasting. Long-term HIV-infected children may be shorter than expected and have less lean body tissue.

Many challenges face children with HIV and their care providers. Aside from the problems of malnutrition, these children may face infections, neurologic problems and developmental delays.

Successes and Challenges: Feed a Cold, Feed a Fever

Research on the differences between HIV-infected children and uninfected children show that weight at birth may be the same, but things can change quickly. T.L. Miller, MD, and colleagues studied 52 HIV positive children and compared their growth and development to 37 children born to HIV positive mothers who seroreverted (became HIV negative within 15 months after birth). While children without HIV began growing in both height and weight, their HIV positive counterparts actually lost weight. Not only did they not reach expected weights at follow-up visits to the clinic (around 20 months of age), there were also significant differences in height and arm muscle circumference. In looking for reasons for the differences, the researchers suggested that the higher energy needs during HIV infection could be a major contributor. They also noted that there may be nutrients lost because of vomiting, diarrhea and malabsorption in the intestines. It seemed that these children lost very important muscle weight. This type of malnutrition can alter the way organs function, can induce intolerance to medications, and may result in more hospitalizations.

Symptoms of diarrhea, bloating and abdominal pain suggest problems of poor nutrient absorption. A study conducted in Baltimore that looked at malabsorption suggested that carbohydrate malabsorption may be common and is an important consideration in the treatment of children with HIV disease. The authors suggested that malabsorption may contribute to slowed growth and development. Other potential problems are the effects of malnutrition leading to further suppression of immune function, and malabsorption of medications used to treat HIV infection and its complications.

Poor absorption of nutrients has been explored by several research groups. Determining the type of malabsorption can help to indicate the best type of intervention. Miller’s group studied malabsorption in 28 HIV positive children. They found that malabsorption of lactose (a milk sugar) was common in these children compared to 45 children who were in the hospital for other reasons. Lactose malabsorption can be a problem when children rely on milk products as a primary source of nutrition. Another absorption test was performed to check absorption of other carbohydrates (using d-xylose). This test showed that 17 of the 28 HIV positive children did not absorb carbohydrates as well as expected. However, these findings did not predict growth failure in the children studied. The authors suggested that there are probably many factors that contribute to growth failure, and malabsorption is just one.

Though there seems to be much less research and information on the problems of malnutrition and wasting in pediatric HIV disease, there are many parallels to draw from other pediatric disease states. Lessons learned from failure-to-thrive and growth failure in other diseases can help children with HIV disease and their families.

Nutritional Needs

Specific nutritional needs vary from person to person, but some general guidelines apply. Required amounts of fluids, calories, protein and other nutrients are contained in the Recommended Dietary Allowances (National Academy of Sciences, 1989) and are adjusted according to an individual child’s needs.

Dehydration can be the most serious issue facing a child with HIV. It is essential for the body to have enough fluids to process drugs and nutrients and to carry out life functions. Symptoms that suggest dehydration include weight loss of more than 1% per day, dry mouth, increased thirst, decreased urine output, constipation and fever. Dehydration is treated by replacing fluids. Fluids may include soup, juice, milk and gelatin, as well as water. Fluid needs are based on weight and can be estimated using Table 2.

Table 2. Fluid Needs for Pediatric Patients*

Weight (pounds)	Fluid Requirement (cups)	Add for each degree above normal body temperature	Add at least this amount in high temperature environments
10	1.9	0.1	0.9
15	2.8	0.2	1.4
20	3.8	0.3	1.9
25	4.5	0.3	2.2
30	4.9	0.4	2.5
35	5.4	0.4	2.7
40	5.9	0.4	2.9
45	6.3	0.5	3.1
50	6.5	0.5	3.2
55	6.7	0.5	3.3
60	6.9	0.5	3.4
65	7.0	0.5	3.5
70	7.2	0.5	3.6
75	7.4	0.5	3.7
80	7.6	0.5	3.8
85	7.8	0.6	3.9
90	8.0	0.6	4.0
95	8.2	0.6	4.1
100	8.4	0.6	4.2
110	8.8	0.6	4.4
120	9.1	0.7	4.6
130	9.5	0.7	4.8
140	9.9	0.7	4.9
150	10.3	0.7	5.1

*Fluids should be increased with fever, sweating or consistently hot environments. A child might need up to a cup more of fluid per 1000 calories to replace fluid lost as sweat. Calculate calories and divide by 1000 to get additional cups of fluid needed.

Children who experience growth retardation and other signs of malnutrition may require additional nutrients--especially calories and protein--to catch up with a normal growth curve. Estimated calorie needs by age are shown in Table 3. These estimates may not meet individual needs, so continuous monitoring of growth is important in adjusting goals on a periodic basis.

Pediatricians typically monitor growth curves, which are levels of weight gain or growth in height based on age. If a child is at less than the fifth percentile in weight for his or her age, the diagnosis may be "underweight." If the child is below the fifth percentile in weight for height, he or she may be considered underweight with wasting or acute undernutrition which may be short-term. If the child’s height is less than the fifth percentile for age, then the diagnosis may be stunted growth and chronic (or long-term) undernutrition.

If a child starts in a certain percentile or baseline level, he or she would be expected to grow along the same or a higher curve over time. If growth proceeds but the child drops in level from, say, the 50th percentile to the 20th percentile, then it can be a sign of losing nutritional and developmental ground. If this happens, it is important to evaluate the causes of inadequate growth. Any problems detected can then be addressed both individually and in context to provide the best approach.

Actual nutrient intake (e.g., fluids, calories, protein) can be evaluated by keeping a diary of the child’s intake. This can then be compared to estimated nutrient needs. Reasons for inadequate food or formula intake may include symptoms (e.g., loss of appetite, feeling full early, diarrhea, mouth sores, nausea and vomiting, pain), psychosocial issues (e.g., depression, fear, control, family issues) and economic issues (e.g., food or formula access, access to medical care, economic resources).

Calorie needs are estimated based on age, weight, need for catch-up growth and any special conditions (see Table 3). Suggested food groups and serving sizes are shown in Table 4. Serving sizes will vary according to the age of the child.

Table 3. Recommended Baseline Calorie Levels*

Age (years)	Girls 50th Percentile Weight (pounds)	Boys 50th Percentile Weight (pounds)	Calories/Pound for "weight age"	Estimated Protein Needs (grams)
2	26	27	46	16
3	31	32	46	16
4	37	37	41	24
5	40	41	41	24
6	43	45	41	24
7	48	50	32	52
8	55	55	32	52
9	63	62	32	52
10	71	69	32	52
11	81	77	**G: 21;B: 25	G: 46;B: 45
12	90	88	G: 21;B: 25	G: 46;B: 45
13	101	99	G: 21;B: 25	G: 46;B: 45

*Racial background differences exist. Children of Asian or Hispanic descent may weigh less than these tables predict without indication of malnutrition. Check with your pediatrician and pediatric dietitian.

**G = girls; B = boys

Table 4. Food Groups and Serving Sizes

Food group	Age group: 2-3 years		Age group: 4-6 years		Age group: 7-12 years
	servings	portion size	servings	portion size	servings	portion size
Milk/dairy	4-5	½ cup or 4 oz.	3-4	½-¾ cup or 4-6 oz.	3-4	½-1 cup
Protein	2	1-2 oz.	2	1-2 oz.	3-4	2 oz.
Fruit/ vegetable	4-5	2-3 table- spoons (a few pieces) 3-4 oz. juice	4-5	3-4 table- spoons (a few pieces) 4 oz. juice	4-5	¼-½ cup (several pieces) 4 oz. juice
Bread/ grain	3-4	½-1 slice ¼-½ cup cooked cereal ½-1 cup dry cereal	3-4	1 slice ½ cup cooked cereal 1 cup dry cereal	4-5	1 slice ½-1 cup cooked cereal 1 cup dry cereal

Special Feedings and Formulas

Making sure that all dietary needs are met is not always easy. The task is complicated by medications, symptoms and family dynamics that surround HIV disease. In cases of loss of appetite, diarrhea or other problems that prevent adequate intake, special feedings and formulas can help to bridge the gap. A multidisciplinary team that includes a physician, nurse, dietitian, social worker and others who support the family’s efforts can help to alleviate some of the stress and frustration that feeding a child with HIV can cause.

If symptoms are a problem, it can help to discuss with the healthcare team dietary strategies and medications that may reduce symptom severity. Diarrhea is one of the most common reasons for visits to a pediatrician. Dehydration and nutrient loss due to diarrhea may become important issues. Special products for replenishing fluids include Rehydrolyte and homemade oral rehydration solutions. To prevent dehydration during times of high fever, sweating and hot weather, clear liquids can help. These include popsicles, gelatin, juices and broths. Commercial products designed to maintain hydration include Ricelyte, Pedialyte and Resol.

Additional strategies to deal with diarrhea include antidiarrheal medications and low-residue diets designed to reduce the amount of feces (stool weight). Low residue diets limit the amount of fat, fiber and milk in the diet. In such a diet, emphasis is placed on low-fat protein choices (such as skinless cooked chicken or fish), low-fiber starches (such as white bread and white rice), canned fruits and vegetables, and limited dairy products with some milk substitutes.

Lactose intolerance should be considered, especially if symptoms happen after eating or drinking dairy products. Lactose-reduced milk and dairy food substitutes can be used. These include soy milk, rice milk, reduced-lactose milk and commercial soy-based formulas (such as Isomil, Prosobee or Nursoy). Lactase enzyme products may make milk and other dairy products more tolerable.

Fat intolerance and malabsorption may be additional challenges in children with HIV. Low-fat food choices (trimmed and skinless meats, baked or boiled foods rather than fried) can keep nutrient quality high while reducing symptoms. Intestinal and pancreatic enzyme supplementation may also improve tolerance of higher fat foods if calories are an important issue.

Mouth sores can become a major impediment to eating. Soft-textured, moist foods can be offered. In this case, the child may have to avoid foods that are spicy or acidic (e.g., citrus fruits, tomato) and foods with a rough or dry texture (e.g., chips, crackers).

Problems swallowing and chewing, delayed motor skill development (especially in children who cannot feed themselves) and severe loss of appetite may require more aggressive management with appetite stimulant medications or nonvolitional feeding. Nonvolitional feeding does not require self-feeding effort, and includes feeding through a tube directly into the stomach or intestines. This type of feeding allows the intestines to continue to function as fully as possible while nutritional rehabilitation takes place. Special formulas can provide for complete nutrition until the child is well-nourished enough to eat. In cases of severe intestinal malabsorption of nutrients, it might be necessary to introduce nutrients directly into the bloodstream. This type of feeding is called total parenteral nutrition (TPN). Though these nonvolitional methods of getting nutrients can be started if necessary, it is best to use oral feeding whenever possible. Oral feeding not only relies heavily on food-based nutrients, but allows the development of normal daily eating routines.

Food Safety

Regardless of the chosen method of feeding, sanitation and safe preparation are primary issues, especially for children who have compromised immune systems. Persons who handle food should be aware of several considerations to make sure that the food and formula provided to children with HIV is safe. These guidelines are not uniquely designed for persons with HIV disease, but they may be more crucial when immune defenses are suppressed.

Careful hand-washing is one of the most important factors in food safety. Both food-handlers and the child who will be eating should thoroughly wash their hands in warm soapy water and completely rinse them before, during and after preparing food. The mechanical act of "scrubbing" is as important as the use of soap. Items used in food preparation and serving (including knives, cutting boards, bowls and utensils) should be sanitized between uses. Hot, soapy water followed by thorough rinsing; a dishwasher with water temperature set to hot; and rinses with bleach or iodine solution will help prevent food-borne illness.

Starting in the grocery store, food safety should be kept in mind. Shop for perishable items just before check-out time. Food should be brought home and stored immediately after shopping. Refrigerated foods should be kept below 40 degrees F and frozen foods should be kept below 0 degrees F. Check thermometers in the refrigerator and freezer occasionally (especially in the summer). Foods should be well wrapped to prevent cross-contamination between items such as raw meat and raw vegetables.

When preparing foods, clean the lids of cans and jars before opening them to help prevent contamination. Eggs and other high-protein foods should be handled with care and thoroughly heated to a well-done stage (160 degrees F or more on a food thermometer).

To rinse fresh foods, it may be best to use water that has been boiled for at least 1 minute and then cooled, or adequately filtered water. When looking for a filter, an acceptable rating is one that filters down to 1 micron or says "NSF standard 53 for cyst reduction" on the label.

It may take a little planning to defrost items in the refrigerator. A microwave oven can be used to defrost foods. Protein-containing foods (e.g., meats, dairy products) should not be defrosted or held at room temperature (during defrosting, handling and serving) for more than an hour or so. Hot foods should be kept hot (above 140 degrees F) and cold foods should be kept cold (below 40 degrees F).

Store leftovers as soon as possible. Shallow containers allow food to cool best in the refrigerator. Because odor is not the safest method to determine food safety, label foods with dates. Hot food leftovers stored in the refrigerator should be heated to 160 degrees F or higher before serving. Such foods should probably be tossed out after about 3 days.

Proper food storage also prevents infestation with insects, rodents and the like. If infestation happens, avoid using foods that may be contaminated and seek professional advice on dealing with the problem.

Prevention is the best method of dealing with food-borne illness. If a child experiences food poisoning, a pediatrician should be contacted promptly. Keeping the child well hydrated (plenty of fluids) and replacing lost nutrients will be of utmost importance in recovery.

What to Watch

Providing the much-needed nutrients for growth and maintenance is extremely important for a child with HIV disease. Problems can arise which may result in malnutrition. Care providers can keep an eye on progress in growth and development. Families can keep the healthcare team informed of any events, problems or achievements that require attention. Questions should be openly discussed among family members, care providers and healthcare team members, with respect given to cultural diversity and the coping ability of the child and his or her family.

Page last updated 9 July 1998