Carmen Casanovas, Technical Officer at WHO's Department of Nutrition for Health and Development, who reviewed and finalized the document. Ann-Beth Moller, Technical Officer at WHO's Department of Nutrition for Health and Development, who reviewed and edited the document and assisted in the approval process.
Introduction
Sections of these guidelines need to be adapted at the country level to reflect local dietary practices, national policies and protocols for food and nutrition assistance, and protocols for managing severe malnutrition. Although the guidelines are intended to be comprehensive and self-explanatory, training is required so that practitioners are familiar with the layout and content and understand how these guidelines can be used routinely.
SECTION ONE - ASSESS, CLASSIFY AND DECIDE A NUTRITIONAL CARE PLAN
- A SSESS AND CLASSIFY THE CHILD ’ S GROWTH
- Assess and classify child’s weight and growth
- A SSESS THE CHILD ’ S NUTRITIONAL NEEDS
- Assess the child’s nutritional needs
Weight loss or failure to gain weight can be identified by observing the child's weight over time. Has the child lost weight in the last month? this may be due to HIV-related chronic lung disease such as LIP, bronchiectasis or tuberculosis).
LOOK and FEEL
D ECIDE A N UTRITION C ARE P LAN
These children also need ART and should be referred to a treatment site for TB evaluation and exclusion. Severely malnourished children with medical complications should be hospitalized for medical care including therapeutic feeding.
When to change Nutritional Care plans
GIVE IN ADDITION TO MEALS AND SNACKS SUITABLE FOR THE CHILD'S AGE 6-11 months [additional 60-75 kcal = Total ~760 kcal/day]. If the child's diet is not balanced, provide a daily micronutrient supplement providing 1 RDI of a wide range of vitamins and other micronutrients (see national guidelines).
SECTION TWO – IMPLEMENT THE NUTRITION CARE PLAN
W HAT DOES THE CHILD EAT AND DRINK ?
- Ask about milk intake
- Ability to eat (past 48 hours)
As the HIV infection progresses and the child suffers from other infections, the amount of extra energy needed increases. In these situations, parents or carers or the child themselves should choose foods wisely to ensure that the best balance of foods is achieved. In most cases, a balanced diet, where the child eats a variety of foods, is better than specialized supplements.
If a child is not growing well, or there has been recent weight loss or growth is faltering, or the child is underweight, check what the child is eating and drinking. If no solid food has been eaten in the last 4 meals, or only milk taken in the last 24 hours, it is classified as severely malnourished. In children with severe malnutrition, assess whether the child has a good appetite and decide whether the child can be managed at home or needs to be hospitalized.
D ISCUSS WHO GIVES THE CHILD HIS / HER FOOD AND HOW THE CHILD EATS
Feed slowly and patiently and encourage the child to eat, but do not force them. If the child refuses many foods, try different food combinations, tastes, textures and encouragement methods. Has the care of the child or household circumstances changed since the last visit or within the last 4 weeks.
If the carer or circumstances (c) have changed in the last 4 weeks, then classify as Caring not stable. If the mother lives in another household or is dead or ill, then also classify as Care not stable. Schedule review of the child in 4 weeks to make sure he/she is being adequately cared for.
A SSESS IF THERE IS FOOD AND INCOME AT HOME
- Food access (past 4 weeks) a. Have there been days in the
Assess access to food and financial support. local adaptations to these guidelines should include resources/responses as appropriate). If classified as 'Serious food shortage', refer urgently to local Family Food Support services. Have there been days in the past 4 weeks when there was not enough food available to feed the child?
If classified as 'Food Deficient' then refer to local services and other community resources for consideration of Family Food Support. If food shortages are identified, programs should explore ways to assist the parent/caregiver, which may include providing food support. These criteria have not been formally tested in the context of HIV to know whether they are valid and useful.
D ISCUSS EXERCISE AND AVOIDING RISK FACTORS FOR MALNUTRITION
Many mothers and fathers infected with HIV feel very guilty that they have 'given' HIV to their child and do not know how they can help the child to stay well and be able to enjoy life. HIV-infected children who develop measles have a more severe disease and are more likely to die. All HIV-infected children should receive prophylactic cotrimoxazole following the guidelines given below to prevent PCP pneumonia.
In a child or infant exposed to HIV ONLY once, HIV infection has been ruled out for sure and at least six weeks have passed since breastfeeding has been completely stopped. ¾ HIV-exposed child or infant <18 months – negative virologic testing if performed 6 weeks after complete cessation of breastfeeding usually indicates that the infant is not infected. ¾ For a breastfed HIV-exposed child > 18 months - negative HIV antibody test 6 weeks after complete cessation of breastfeeding usually indicates that the child is not infected.
D ECIDE IF TO REFER AND WHEN TO REVIEW
A child who is unwell and/or showing signs of stunted growth or has recently had diarrhoea. Weekly Only if he meets the criteria for home treatment and there is no immediate need for other tests requiring hospitalization.
SECTION THREE – CHILDREN WITH SPECIAL NEEDS
T HE HIV- INFECTED CHILD WITH SPECIAL NEEDS
- Eating during and when recovering from an illness – see Suggestion sheet 1 It is often difficult to encourage children to eat during a febrile illness or when otherwise unwell
- Poor appetite (anorexia) – see Suggestion sheet 2
- Sore mouth or throat – see Suggestion sheet 3
- Change in taste – see Suggestion sheet 4
- Children with diarrhoea – see Suggestion sheet 5
- Nausea and/or vomiting – see Suggestion sheet 6
Children infected with HIV can be expected to experience many difficulties during their lives. If this weight is not recovered in the weeks following the illness, then the child's growth curve is likely to drop to a lower level in the long term. Despite these, the child can often still be managed at home if the right help is provided early.
This can be due to mouth ulcers, an acute illness or because HIV infection itself can cause a loss of appetite. Oral hygiene such as rinsing the mouth with clean water before and after meals and cleaning the teeth are important and can help the child feel better. A child should be seen at the clinic if the diarrhea continues for more than three days or if there is fever or blood in the stool.
C HILDREN ON ANTIRETROVIRAL TREATMENT
- Has there been any change in eating patterns or appetite since the last visit?
- Has the child vomited? If yes, has there been any fast breathing/fever? – see below
- Since the last visit has the child been taking any other medicines from a doctor/pharmacy/programmes, or from other sources including traditional
- Have you noticed any change in body shape or appearance of the child?
Once the child has gained weight, he/she will only need the usual energy and protein requirements for his/her age and the extra 10% because he/she has HIV infection (see step 2). Growth faltering may indicate a change in caregiving conditions or there may not be enough food available. Check mom/dad's health and assess if either needs ART.
Development of immune reconstitution syndrome (expected only in the first 3 months of starting ART). Since the last visit, the child has received any other medication from a doctor/pharmacy/program, or from other sources, including traditional doctors/pharmacies/programs, or from other sources, including traditional medicine. Children referred for weight loss should be followed up after discharge from the referral center and growth monitoring should be done on a regular basis (at least monthly, although it may be necessary to return the child more often or to be hospitalized for observation) ).
What to do if the child has nausea and vomiting when taking antiretroviral drugs
Any child on ART who exhibits these symptoms should be referred promptly to rule out lactic acidosis, especially if any of the symptoms are severe or there are IMCI danger signs. There are no good screening tests to detect lactic acidosis, and a high index of suspicion should be maintained. Any child with a reading above 7 mmol/l should be referred for a formal fasting glucose and beyond.
It should be sought in all children who have been on ART for more than 6 months. Children with suspected lipodystrophy should be referred to their ART site for evaluation and follow-up. Children on ART require regular monitoring of their viral and immune response and potential metabolic and other adverse effects.
United Nations University, World Health Organization, Food and Agriculture Organization of the United Nations, Rome, 2004. Consensus Statement of the Core Group of the TB/HIV Working Group of the Stop TB Partnership. WHO Child Growth Standards: Methods and Development: Head Circumference for Age, Arm Circumference for Age, Triceps Skinfold for Age and Subscapular Skinfold for Age.
WHO Child Growth Standards: Methods and Development: Length/height-for-age, weight-for-age, weight-for-height, weight-for-height, and body mass index-for-age.
Staging criteria for children infected with HIV
Appendix II– Composition of different Therapeutic Feeding options
Appendix III– Home-based foods to increase energy intake
Suggestion sheets to improve food intake
What to try if the child does not feel like eating. Adjust according to local practices). On days when the child feels well or eats well, try to give extra meals. Feed the child refined cereals rather than whole grain cereals and flour while he/she has diarrhoea.
Encourage the child to drink fluids about half an hour after meals, rather than during meals. On days when the child feels well, try to increase the quantity and variety of food intake. Once the illness has passed, be sure to give the child an extra meal (or a larger amount per meal) to make up for missed meals.
Guiding Principles for Complementary Feeding of the Breastfed Child (2003)
Increase the number of times the child is given complementary foods as he/she gets older. If the energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be necessary. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, favorite foods.
After illness, feed more often than usual and encourage the child to eat more. The guidelines are intended to guide policy and programmatic action at global, national and community levels. The 'Guiding Principles for Complementary Feeding of the Breastfed Child (2003)' was written by Kathryn Dewey.
Guiding principles for feeding non-breastfed children 6-24 months of age (2005)
Their implementation will require further research in most settings to identify culturally acceptable and affordable foods that can be promoted in meal preparation and as snacks, to identify factors that facilitate or are barriers to adopting improved feeding behaviors by caregivers and families, and to translate each guideline into specific messages understood by health care providers, mothers, and other caregivers. 'Guiding principles for feeding non-breastfed children aged 6-24 months' was written by Kathryn Dewey based on the conclusions of an informal meeting on feeding non-breastfed children convened by the WHO Division of Child and Adolescent Health and Development ( CAH ) and Nutrition for Health and Development (NHD) in Geneva, 8-10 March 2004.
Five Keys to Safer Food 9
Keep clean
Separate raw and cooked foods
Cook thoroughly
Keep food at safe temperatures
Use safe water and foods
The content of these guidelines acknowledges that wasting and undernutrition in HIV- infected children reflect a series of failures within the health system, the home and
The guidelines do not cover the feeding of infants 0 to 6 months old, because the specialised care in this age group is already addressed in other WHO guidelines and
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