Atlas of Paediatric HIV Infection

CHAPTER 11: MALNUTRITION AND HIV

Figure 100: Interaction between HIV infection and nutritional status in children

Malnutrition is high among HIV-infected children especially in developing countries, where it is already endemic. Severe malnutrition is predictive of HIV; 30—50% of severely malnourished children are HIV-infected in settings where both conditions are endemic.

Stunting (low height for age) is a more prominent feature than wasting in HIV associated malnutrition. Micronutrient deficiencies (low serum levels of zinc, selenium, vitamins A, E, B6, B12 and C) is also common among HIV-infected children. HIV-related malnutrition could result from reduced food intake (poor appetite, oral infections such as candidiasis), increased metabolism and poor absorption of nutrients mainly due to diarrhoeal diseases.

Unexplained moderate malnutrition not adequately responding to standard therapy is classified as stage 3 disease. Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy is a clinical stage 4 disease.

Diagnosis

  1. Weight, height and occipitofrontal circumference (OFC) should be plotted on available growth charts (WHO growth standards available at www.who.int/childgrowth/training/en). - SD Z scores for weight, height/length, OFC (from -2SD to -3SD is severe)
  2. Severe wasting can also be demonstrated by measuring the mid upper arm circumference (MUAC):

Treatment

It is recommended that children with severe acute malnutrition (SAM) are managed in the institution until there is nutritional recovery, ≥90% weight for height. Generally, this would require admission for up to 4 weeks. Children can be discharged once they have achieved >10 g/day weight gain, are taking a solid diet, have a good appetite, show no oedema.

Ready to use foods (RTUF) e.g. plump nuts, a new peanut butter based F100 preparation is useful as therapeutic and supplemental feed in the management of severe malnutrition.

Complications

Mortality is five times higher in severely malnourished HIV-infected than in uninfected children.

Further readings:

  1. WHO. Antiretroviral Therapy for HIV infection in children and infants: Toward Universal Access. Recommendations for a public health approach. 2010 revision. Available from: http://whqlibdoc.who.int/publications/2010/9789241599801_eng.pdf.
  2. Duggal S, Chugh TS, Duggal AS. HIV and Malnutrition: Effects on Immune System. Clinical and Developmental Immunology 2012; 1-8.
Figure 101: Plump Nuts
Figure 102:Severe malnutrition: MUAC 10.5 cm.
Figure 103a: Severe wasting
Figure 103b: Marasmus with gluteal skin folds (“baggy pants” sign).
Figure 104: Severe wasting with hair changes in HIV infection.
Figure 105a: At first diagnosis
Figure 105b & c: (b) After 2 weeks on care (c) After 4 weeks on care.
Figure 106a & b: Severe wasting and flaky paint desquamation on the lower limbs of an HIV-infected child.
Figure 107a & b: 8-year-old boy with severe acute malnutrition plus oedema. He had symptomatic hypocalcaemia with carpal spasm demonstrated. The spasm resolved with intravenous calcium gluconate.
Figure 108:Angular stomatitis due to riboflavin (vitamin B2) deficiency.