Clinicians should perform an annual nutritional assessment as part of routine care for all human immunodeficiency virus (HIV)-infected children
Elements of a Nutritional and Dietary Assessment
- Anthropometric data, including height, weight, and head circumference
- Biochemical data with lipid panel and albumin or pre-albumin
- Medications with nutritional side effects and interactions with foods
- Appetite and intake (24-hour recall or 3-day record)
- Family food access issues
- Social history/behavior issues/cultural practices
- Oral health
- Supplement use (including multivitamins, herbal therapies, teas)
- Activity level
- Food allergies
- Medical diagnoses, symptoms, and HIV classification
- Developmental problems
Growth Abnormalities in Perinatally HIV-Infected Children and Adolescents
Clinicians should obtain weight and height (or length) measurements every 3 to 4 months until children have reached full adult height.
Clinicians should assess children who are experiencing suboptimal growth for potentially reversible causes of poor growth.
Refer to Figure 1 in the original guideline document for causes of malnutrition.
Restoration of Growth
Energy Intake
Clinicians should carefully evaluate the dietary intake of children with growth failure or wasting syndrome, and dietary counseling should be provided by a health professional with expertise in pediatric nutrition.
Clinicians should increase total caloric intake as needed for growth, and potential causes of growth failure should be treated when possible.
Caloric intake should be nutritionally balanced: 50% to 55% of total calories from carbohydrate; 15% to 20% from protein; and 20% to 30% from fat (with less than 10% of total calories as saturated fatty acids).
Refer to Table 2 in the original guideline document for information on common antiretroviral (ARV) side effects that may affect appetite and nutrition.
Viral Suppression
Clinicians should assess the ARV regimen of patients with poor growth and high viral load to ensure optimal efficacy of the ARV regimen.
Micronutrients
Clinicians should prescribe multivitamin and mineral supplements for HIV-infected children with growth problems but should be careful of the potential for overdose.
Clinicians should ensure that any micronutrient supplements that are used conform to the specific recommended dietary allowances (RDA) for age.
The clinician should obtain a history of use of over-the-counter supplements and herbal supplements.
Anabolic Agents
Anabolic agents should only be prescribed for children in consultation with a pediatric HIV specialist.
Neuroendocrine Disorders and Growth
In patients with unexplained growth failure, clinicians should obtain thyroid function tests.
Clinicians should refer patients to an endocrinologist when growth failure remains unexplained after initial evaluation or when the evaluation suggests an endocrine abnormality.
Association of Growth Abnormalities with Gastrointestinal Infections and Malabsorption
Clinicians should carefully screen HIV-infected children with poor growth for gastrointestinal infection and malabsorption.
When lactose and fat intolerance is suspected, the clinician should consult with a pediatric gastroenterologist for screening and diet adjustment.
Lipodystrophy and Abnormalities of Lipid Metabolism
Clinicians should screen serum cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein in HIV-infected children initiating highly-active antiretroviral therapy (HAART) 3 to 6 months after initiation and approximately every 6 months thereafter. Abnormal results warrant repeat studies performed in the fasting state.
Refer to Table 3 in the original guideline document for classification of cholesterol levels in children and to the Table below for information on management of hypercholesterolemia in HIV-infected children and adolescents.
Management of HIV-infected Children with Abnormal Cholesterol
Clinicians should use dietary and behavioral interventions to manage HIV-infected children and adolescents with abnormal cholesterol. Monitoring and dietary management should be in accordance with the guidelines published by the American Academy of Pediatrics (for adolescents, the Adult Acquired Immunodeficiency Syndrome [AIDS] Clinical Trials Group Preliminary Guidelines).
Clinicians should consider the use of pharmacologic interventions for patients with markedly abnormal cholesterol; however, there is the potential for drug-drug interactions, particularly between ARV agents and bile acid sequestering agents.
Clinicians should refer HIV-infected children with borderline or high cholesterol to a pediatric nutritionist or dietitian.
Table: Management of Hypercholesterolemia in HIV-Infected Children and Adolescents
Fasting Low-Density Lipoprotein (LDL) Cholesterol Level (mg/dL) |
Management |
Acceptable LDL <110 |
- Education on healthy eating and on risk factors for coronary artery disease (CAD)
- Repeat lipid panel in 1 year
|
Borderline LDL=110-129 |
- Education on risk factors for CAD
- Initiate the American Heart Association Step-One diet (refer to Appendix E in the original guideline document)
- Re-evaluate in 1 year
|
High LDL >130 |
- Examine for secondary causes of CAD, including renal, liver, and familial diseases
- Screen family members for CAD
- Initiate Step-One diet (refer to Appendix E in the original guideline document)
- Follow up in 3 months. If still high, then initiate Step-Two diet (refer to Appendix E in the original guideline document)
|
Abnormalities of Glucose Metabolism
Clinicians should screen for risk factors for diabetes mellitus, including obesity and family history.