ASSESSMENT OF DIETARY INTAKE AND NUTRITIONAL STATUS OF HIV INFECTED
CHILDREN (UNDER FIVE YEARS OF AGE) WHO ARE HIV POSITIVE
Dissertation submitted to
THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY
in partial fulfillment of the regulations for the award of
M.D.DEGREE IN PAEDIATRIC MEDICINE BRANCH VII
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE, SALEM.
APRIL 2016
CERTIFICATE BY THE GUIDE
This is to certify that this the dissertation titled “ASSESSMENT OF DIETARY INTAKE AND NUTRITIONAL STATUS OF HIV INFECTED CHILDREN (UNDER FIVE YEARS OF AGE) WHO ARE HIV POSITIVE”
submitted by Dr.S.Arya Devi to the faculty of Paediatric Medicine, The Tamil Nadu Dr.M.G.R.Medical University, Chennai in partial fulfillment of the requirement for the award of MD Degree Branch VII (Paediatric Medicine), is a bonafide research work carried out by her under my direct supervision and guidance at Government Mohan Kumaramangalam Medical College, Salem during the academic year 2014-2016.
Dr.D.SAMPATH KUMAR, M.D., D.C.H., Associate Professor
Department of Paediatric Medicine,
Govt..Mohan Kumaramangalam Medical College, Salem.
ENDORSEMENT
BY THE HEAD OF THE DEPARTMENT
This is to certify that this the dissertation titled “ASSESSMENT OF DIETARY INTAKE AND NUTRITIONAL STATUS OF HIV INFECTED CHILDREN (UNDER FIVE YEARS OF AGE) WHO ARE HIV POSITIVE” submitted by Dr.S.Arya Devi to the faculty of Paediatric Medicine, The Tamil Nadu Dr.M.G.R.Medical University, Chennai in partial fulfillment of the requirement for the award of MD Degree Branch VII (Paediatric Medicine), is a bonafide research work carried out by her under direct supervision and guidance of Dr.D.Sampath kumar M.D., D.C.H.,
Dr.T.SUNDARARAJAN M.D.,D.C.H., Professor & HOD
Department of Paediatric Medicine,
Govt..Mohan Kumaramangalam Medical College, Salem.
CERTIFICATE BY THE DEAN
This is to certify that this the dissertation titled “ASSESSMENT OF DIETARY INTAKE AND NUTRITIONAL STATUS OF HIV INFECTED CHILDREN (UNDER FIVE YEARS OF AGE) WHO ARE HIV POSITIVE”
submitted by Dr.S.Arya Devi to the faculty of Paediatric Medicine, The Tamil Nadu Dr.M.G.R.Medical University, Chennai in partial fulfillment of the requirement for the award of MD Degree Branch VII (Paediatric Medicine), is a bonafide research work carried out by her under direct supervision and guidance of Dr.D.Sampath kumar M.D., D.C.H., at Government Mohan Kumaramangalam Medical College, Salem during the academic year 2014-2015.
Date: Place:
Dr. R..RAVICHANDRAN M.S., MCH., Dean
Govt..Mohan Kumaramangalam Medical College, Salem.
DECLARATION
DECLARATION BY THE CANDIDATE
I here declare that this dissertation entitled “ASSESSMENT OF DIETARY INTAKE AND NUTRITIONAL STATUS OF HIV INFECTED CHILDREN (UNDER FIVE YEARS OF AGE) WHO ARE HIV POSITIVE” in GMKMCH is a bonafide and genuine research work carried out by me under the guidance of Dr.D.SAMPATH KUMAR, M.D., D.C.H., Assistant Professor Department of Paediatric Medicine,, Government Mohan Kumaramangalam Medical College, Salem.
I have not submitted this previously to this university or any other university for the award of any degree or diploma
Dr. S.Arya Devi
Postgraduate in Pediatric Medicine, Department of Paediatric Medicine,
Govt..Mohan Kumaramangalam Medical College, Salem.
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
I gratefully acknowledge and sincerely thank our beloved Dean Dr.R.RAVICHANDRAN M.S., MCH., Government Mohan Kumaramangalam Medical College and Hospital, for his whole hearted co-operation and support for the completion of this dissertation.
I am grateful to Prof. Dr. T.S. SUNDARARAJAN, M.D., D.C.H., Professor and Head of department of Pediatrics, Government Mohan Kumaramangalam Medical College and Hospital, for permitting me to do the study and for his encouragement.
My sincere thanks to DR.D.SAMPATH KUMAR M.D., D.C.H., Associate Professor, Department of Pediatrics, Government Mohan Kumaramangalam Medical College and Hospital, who has provided constant encouragement and guidance in the preparation of this dissertation.
I am sincerely grateful to my Associate Professor DR.P.SAMPATHKUMAR, M.D., D.C.H. for his guidance and help in conducting this study.
I extend my sincere thanks to my Registrar Dr.SURESH KANNAN, for his invaluable suggestions during my study.
I extent my sincere thankfulness to all my Assistant Professor of Paediatrics for their valuable guidance in this study.
I sincerely thank ART medical officer of our college for his valuable support during the study.
I am grateful to all my colleagues for their full cooperation in this study and my heart filled thanks to all my patients and their caretakers who helped me in conducting this study.
I sincerely thank my family and my husband for helping me successfully complete this study.
Grade
Minutes of Meeting:
Ref.No.5694/MEI/P.G/2015 Office of the Dean, Govt.Mohan Kumaramangalam,
Medical College, Salem-30.
Dated: 02.2015
Ethical committee meeting held on 08.01.2015 at 11.00 A.M in the seminar hall, IInd Floor, Medicine Block, Govt.Mohan Kumaramangalam Medical College Hospital, Salem 01
The following members were attended the meeting MEMBERS:
1. Dr.N. Mohan, MS., FICS. FMMC. Dean, Govt.Mohan Kumaramangalam Medical College Hospital, Salem.
2. Dr.A.P.Ramasamy, MD., Chairman, ECRB, External Clinician.
3. Dr.V.Dhandapani, MD., Deputy Chairman, External Social Scientist, ECIRB.
4. Mr.S.Shanmugham, BSc. BL, Advocate, External Legal Expert.
5. Mrs. Ruby Thiyagarajan, Secretary, YWCA, Salem-Social Worker.
6. Dr.T.Swaminathan, MS., Medical Superintendent, Govt Mohan Kumaramangalam Medical College Hospital, Salem.
7. Dr.S.Mohamed Musthafa, MD., Vice Principal, Govt Mohan Kumaramangalam Medical College Hospital, Salem.
8. Dr.S.Vijayarangan, MD., Associate professor of Pharmacology, Govt Mohan Kumaramangalam Medical College Hospital, Salem.
9. Dr.Priya Jeyapal, MD., Professor and HOD of Biochemistry, Govt Mohan Kumaramangalam Medical College Hospital, Salem.
Sl.No
Name of the Presenter with
Address
Title Name of the Guide and Address
Whether it is approved
or Not
1
Dr. S.Aryadevei, III Year MD., P.G.
Student, GMKMC., Salem-30.
Assessment of Dietary intake and Nutritional status of Children (under 5 years of age) who are HIV /AIDS infected
Dr.D.Sampath Kumar, MD., D.C.H.
Associate Professor Paediatrics Department GMKMC, Salem.
Approved
The ethical committee examined the studies in detail and is pleased to accord ethical committee approval for the above Post Graduate of this college to carry out the studies with the following conditions.
1. She should carry out the work without detrimental to regular activities as well as without extra expenditure to the institution to government.
2. She should inform the institution Ethical Committee in case of any change of study procedure site and investigation or guide.
3. She should not deviate from the area of the work which applied for ethical clearance.
4. She should inform the IEC immediately, in case of any adverse events or serious adverse reactions.
5. She should abide to the rules and regulations of the institution.
6. She should complete the work within the specific period and apply for if any extension of time is required she should apply for permission again to do the work.
7. She should submit the summary of the work to the Ethical Committee on completion of the work.
8. She should not claim any funds from the institution while doing the work or on completion.
9. She should understand that the members of IEC have the right to monitor the worker with prior intimation.
Dr. R.RAVICHANDRAN M.S., MCH., Dean
Govt..Mohan Kumaramangalam Medical College, Salem.
CONTENTS
CHAPTER
NO TITLE PAGE NO
1 INTRODUCTION 1
2 OBJECTIVES 2
3 REVIEW OF LITERATURE 5
4 MATERIALS AND METHODOLOGY 36
5 RESULTS AND ANALYSIS 39
6 DISCUSSION 70
7 SUMMARY 75
8 CONCLUSION 77
9 ANNEXURES 78
i. BIBILIOGRAPHY
ii. PROFORMA
iii. KEY TO MASTER CHART
iv. MASTER CHART
ABSTRACT
ABSTRACT
Background and objectives:
Malnutrition is common problem seen associated with HIV infection. We conducted a study to assess the nutritional status of HIV infected children and various modifiable factors that contributes to the malnutrition
Methods :
55 children less than 5 years who are HIV infected and are attending Salem ART centre were included in the study. A questionnaire was distributed among the caretakers of all these candidates to assess their social status and also their nutritional knowledge and nutritional intake of the children . Anthropometric assessment of nutritional status and laboratory evaluation of micronutrient deficiencies were done.
Results:
Prevalence of wt/age < 2SD was > 50% , stunting and wasting was seen in almost 38% . it was found that nutritional knowledge is significantly associated with nutritional status. Poor nutritional knowledge was seen among the caretakers of more than half of the cases. Majority of the children of these caretakers had poor nutritional status.
Interpretation and conclusion:
HIV is seen significantly associated with malnutrition . modifiable factors that contribute to the poor nutritional status are poor nutritional knowledge of caretakers and poor social background . nutritional status and morbidities were found less among the children of caretakers with good nutritional knowledge and children who take good diet . hence every attempts should be made by health care workers and social workers to ensure that the children take ART medication regularly and take balanced diet.
INTRODUCTION
INTRODUCTION
The human immunodeficiency virus and acquired immunodeficiency syndrome has emerged as one of the greatest threat to global health care system . It is a devastating disease which causes progressive failure of human immune system causing life- threatening opportunistic infections, malignancies and also neurological disorders.
AIDS was recognized as a disease in 1981. This virus was isolated in the year 1983. Two forms of HIV viruses are there, they are HIV- 1 and HIV- 21.Majority of cases in the world are caused by HIV-1.
HIV infection is associated with significant depletion of nutritional status of children. Hence, nutritional status of HIV infected children should be assessed at regular interval as a part of management of the disease, which can be done with anthropometric assessment, measurement of dietary intake, biochemical measurement of serum proteins and micronutrients This is important because malnutrition affects children under five years of age who are HIV infected because of their increased metabolic demands due to the disease as well as increased growth rate . Inadequate breast feeding, low quantity and quality of complementary feeds, lack of adequate nutrition knowledge leading to poor child feeding practices, high rate of infection, all contributes to malnutrition Improvement of nutritional status can improve the quality of living of the children
OBJECTIVE
To evaluate dietary intake and nutritional status of children below five years who are HIV / AIDS positive and find out various factors affecting their nutritional status.
SPECIFIC OBJECTIVES:
• 1) ) assess dietary patterns of children below 5 yrs who are HIV/AIDS Positive
• 2) evaluate nutritional status of children below 5 yrs of age living with HIV/AIDS
• 3)to find out various factors affecting childrens nutritional status of children like the effect of caretakers knowledge, attitude & practices on dietary patterns and health related problems associated with HIV/AIDS that may hinder food intake
SIGNIFICANCE OF STUDY:
The results from the study will help to analyse various causes of malnutrition in HIV infected children and take appropriate measures accordingly.
It is hoped that findings of this study will help to improve feeding by giving health education to health care providers This study will help to improve food intervention programs by policy makers in promotion of health of HIV/AIDS infected children.
Since many studies are not available on this aspect, the results from this study can provide a basis for recommendation on dietary intake for HIV / AIDS infected children and improving their nutritional status.
REVIEW OF LITERATURE EPIDEMIOLOGY OF HIV/AIDS
WHO estimated that in 2012, nearly 35.3 million people are living with HIV in the world. Of these 17.2 million are men, 16.8 million are women and 3.4 million are children less than 15 years of age. In INDIA about 2-5 million HIV infected people are there.
Worldwide 50% of the infected are women, most of who have become infected through heterosexual contact in their child-bearing years.1 Virtually all HIV infected children less than 13 years are infected by vertical transmission from an HIV infected mother.1
The development of Highly Active Antiretroviral Therapy (HAART) as effective therapy for HIV/AIDS has substantially reduced death rate from the disease ( Hommes et al)
Other studies showed that clinical outcome was poor and risk of death was higher in these HIV infected children with compromised nutrient intake which contribute to disease progression (Baum et al)13. Studies have shown that higher level of nutrition knowledge is positively and significantly associated with better dietary quality ( Moore et al)
STRUCTURE OF HIV VIRUS
ETIOLOGY
HIV -1 and HIV-2 are members of retroviridae family and belong to lentivirus genus.
The major external virus protein is gp120 that is associated with gp41;
gp41 is immunogenic and is used in detecting HIV antibodies in diagnostic assays . gp120 carries binding site for CD4 molecule, the most common host cell surface receptor for T lymphocytes. Other CD4 bearing cells are macrophages and microglial cells.
After viral attachment to CD4, gp41 interacts with fusion receptor and virus fuses with cell membrane allowing viral RNA to enter in to cytoplasm of CD4 cells. Viral RNA is converted to DNA by reverse transcriptase, which duplicates to form dsDNA. This proviral DNA enters into cell nucleus and gets integrated with host cell chromosomal DNA . The proviral DNA gets integrated into host cellDNA with the help of integrase. Along with host cell division, integrated proviral DNA gets duplicated.
Proviral HIV DNA is transcribed to RNA and then translated to HIV proteins including gp120 and gp41- the envelope glycoproteins. HIV proteins are assembled into virions in the inner cell membrane and gets budded off from the cell destroying the cell . Each host cell will produce thousands of virions.
MATURE FORM OF HIV VIRUS IN CIRCULATION:
The virions by the action of proteases, an HIV enzyme, cleaves viral proteins and immature virions are converted to mature infectious form.
When there is high volume of HIV replication, errors by HIV reverse transcriptase occurs which results in mutation, this produces strains that are resistant to drugs and host immunity.
Infected CD4 lymphocytes have half life of 2 days which is less compared to other non infected cells. The normal CD4 count is nearly 750 /microL.
Immunity of patients are less affected till the count is more than 350/microL.
When the count drops below 200/microL, patient gets clinical disease due to variety of opportunistic pathogens
Due to HIV infection, cell mediated immunity is mainly affected since it leads to significant loss of CD4 cell count. CD4 cell depletion result from cytotoxic effects of HIV replication, cell mediated immune cytotoxicity and due to thymic damage which will affect lymphocyte production.
Humoral immune system is affected by causing hyperplasia of B cells in lymph nodes, leading to lymphadenopathy and there will be increased production of antibodies to previously met antigens leading to hyperglobulinemia. But the response to new antigens including vaccines decreases.
Table shows paediatric HIV classification based on CD4 T cell count and percentage of total lymphocytes.1
Clinical classification:
N: no signs or symptoms
A: mild signs and symptoms
B: moderate signs and symptoms
C: severe signs and symptoms Immunological
definition1
CD4 count (<12Months) CD4 % (<12 Months) CD4 count (1-5 yr) CD4 % (1- 5yr) CD4 Count (6 – 12 yr) CD % (6-12 yr) 1.No evidence
of suppression
≥1500
micro L ≥25 ≥1000
micro L ≥25 ≥500
micro L ≥25 2.Evidence of
moderate suppresion
750-1499 15-24 500-999 15-24 200-499 15-24 3.Severe
suppression <750 <15 <500 <15 <200 <15
CATEGORY N : NOT SYMPTOMATIC1
No signs or symptoms considered to be the result of HIV infection or have only 1 of the conditions listed in category A.
CATEGORY A: MILDLY SYMPTOMATIC1
2 or more conditions listed but none of the conditions listed in category B & C.
· Lymphadenopathy
· Hepatomegaly
· Splenomegaly
· Dermatitis
· Parotitis
· Recurrent or persistent upper respiratory tract infection, sinusitis, otitis media.
CATEGORY B: MODERATELY SYMPTOMATIC1
Symptomatic conditions other than those listed for category A or C that are attributed to HIV infection.
· Anemia,
· Neutropenia and /or thrombocytopenia persisting for more than 30 days
· Bacterial meningitis, pneumonia, sepsis.
· Candidiasis, oropharyngeal persisting in children older than 6 month of age
· Cardiomyopathy
· CMV infection with onset before 1 month of age
· Diarrhoea, recurrent or chronic
· Hepatitis
· HSV stomatitis, recurrent
· HSV bronchitis, pneumonitis or esophagitis with onset before 1 month of age
· Herpes Zoster involving atleast 2 distinct episodes or more than 1 dermatome
· Leiomyosarcoma
· Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex
· Nephropathy
· Nocardiosis
· Persistent fever
· Toxoplasmosis, onset before 1 month of age
· Varicella, disseminated
CATEGORY C: SEVERELY SYMPTOMATIC1
· Serious bacterial infections, multiple or recurrent
· Candidiasis, esophageal or pulmonary
· Coccidiodomycosis, disseminated ; Cryptococossis, extrapulmonary
· Cryptosporidiosis or isosporiasis with diarrhoea persisting more than 1 mo
· CMV disease with onset of symptoms after 1 month of age
· Encephalopathy
· HSV infection causing a mucocutaneous ulcer that persists for greater than 1 month or bronchitis, pneumonitis or esophagitis for any duration affecting a child older than 1 month of age
· Histoplasmosis, disseminated
· Kaposi sarcoma
· Lymphoma, primary, in brain
· Lymphoma, small, noncleaved cell, or immunoblastic; or large-cell lymphoma or B-lymphocyte or unknown immunologic phenotype.
· Mycobacterium tuberculosis infection, disseminated or extra-pulmonary
· Mycobacterium, other species or unidentified species infection, disseminated
· Pneumocystis jiroveci pneumonia
· Progressive multifocal leukoencephalopathy
· Salmonella septicaemia, recurrent
· Toxoplasmosis of the brain with onset after 1 month of age
· Wasting syndrome in the absence of a concurrent illness other than HIV infection.
WHO CLINICAL STAGING OF PAEDIATRIC HIV:
STAGE 1:
-No symptoms
-Persistent generalised lymphadenopathy
STAGE 2
-Persistent hepatospleenomegaly -Papular pruritic eruptions -Extensive warts
-Extensive molluscum contagiosum -Fungal infection of nail
-Oral ulcerations – recurrent -Persistent parotid enlargement -Lineal gingival erythema -Herpes zoster
-Chronic URI
STAGE 3:
-Moderate malnutrition, not responding to therapy -Persistent diarrhoea
-Persistent fever -Oral hairy leukoplakia -Persistent oral thrush
-Acute necrotizing ulcerative gingivitis -Lymph node TB
-Pulmonary TB -Recurrent pneumonia
-Lymphoid interstitial pneumonia -Chronic lung disease
-Unexplained anemia, neutropenia, thrombocytopenia
STAGE 4:
-Severe malnutrition not responding to standard therapy -Pneumocystis pneumonia
-Severe and recurrent bacterial infections -Chronic infection by Herpes Simplex -Extra pulmonary TB
-Kaposi sarcoma
-Esophageal candidiasis -CNS toxoplasmosis -HIV encephalopathy
-CMV retinitis or other organ infection by CMV -Extra pulmonary cryptococcosis
-Disseminated mycosis -Chronic cryptosporidiosis -Chronic isosporiosis
-Disseminated infection by non tuberculous mycobacterium -Cerebral / B cell non-Hodgkins lymphoma
-Progressive multifocal leukoencephalopathy -HIV associated nephropathy /cardiomyopathy
TRANSMISSION OF HIV TO CHILDREN
The primary route of transmission of infection to children occurs by vertical transmission.2 Vertical transmission can occur before (intrauterine), during (intrapartum), or after delivery (through breast feeding) .It is generally accepted that 30-40% of infected newborns are infected in utero because this percentage of infants have laboratory evidence of infection (positive viral culture or PCR) within 1st week of life.
The highest percentage of HIV infected children acquire virus intrapartum, evidenced by the fact that 60-70% of infected infants do not demonstrate detectable virus until after 1 week of age.
The mechanism of transmission appears to be exposure to infected blood and cervicovaginal secretions in birth canal, where HIV is found in high titers during late gestation and delivery1. Breast feeding is the least common route of transmission of vertical transmission.
The risk of transmission in chronically infected women is approximately 9-16% but 29-53% in women who acquire infection postnatally, suggesting that viremia experienced by mother during primary infection atleast triples the risk of transamission.
Transfusion of infected blood or blood products has accounted for 3-6%
of all paediatric HIV cases. A small number of cases resulting from sexual abuse have been reported1
PERINATAL HIV TRANSMISSION
Risk of perinatal HIV transmission is high if mother has advanced disease, high viral load, low CD4 count, P24 antigenemia and when mother has not received any antiretroviral therapy. Vaginal delivery, prolonged rupture of membranes, antepartum hemorrhage, chorioamnionitis are also associated with high risk of perinatal transmission.transmission through breast milk is high if breast milk viral load is high, presence of cracked nipples or mastitis and baby is on mixed feeding.2
Estimated risk and timing of risk of transmission of HIV from mother to Child in the absence of intervention.
Timing of HIV infection % of Children at risk
During pregnancy 5 to 10%
During Labour and Delivery 10 to 15%
During breast feeding 5 to 20%
Overall risk without breast feeding 15 to 25%
Overall risk with breast feeding upto 6 months 20 to 35%
PREVENTION OF PARENT TO CHILD TRANSMISSION
The following procedures if followed will help to reduce parent to child transmission:
- HIV counselling and testing should be done to all antenatal mothers with opt out option4
- To ensure the involvement of spouse and family members, move from ANC centric to family centric approach4
- All HIV infected mothers should receive ART medications irrespective of their CD4 count and WHO staging. Regimen preferred is TDC+3TC+EFV4
- Institutional delivery should be provided for all HIV infected pregnant woman
- Provision should be given for care of associated conditions – STI/RTI, TB and other opportunistic infections
- Provide psychosocial support for HIV infected pregnant ladies and nutritional counselling should be provided
- Breast feeding should be started with in one hour of delivery, and continue exclusive breast feeding with in 6 months. After 6 months, complementary feeding should be started.4
- Antiretroviral prophylaxis should be given to the infant for a period of 6 weeks
- Cotrimoxazole prophylaxis and Early Infant Diagnosis using HIV DNA PCR should be started at 6 weeks of age4
- Regular follow up of baby and HIV infected mothers should be done through ANMs, ASHAs and District level networks and other outreach workers.4
Vertical transmission can be reduced to less than 2% if ART is taken by mother during pregnancy, during labour and infant after birth.
TREATMENT FOR MOTHER TO PREVENT PARENT TO CHILD HIV TRANMISSION
MOTHER ESTABLISHED CASE OF HIV
Already on Art Newly detected
Continue ART Sent sample for CD4 and
Refer patient for ART
ART to be started regardless of CD4 cout and WHO staging TDF + 3TC + EFV
Continue ART during labour Delivery and lifelong
INFANTS BORN TO HIV POSITIVE MOTHER:
Start Syrup. nevirapine immediately after birth and continue till 6 weeks of age6 Baby should be started either on exclusive breast feeding or exclusive replacement feeds but not on mixed feeding. 5
At 6 weeks baby should be started on cotrimoxazole based based on dried blood sample test report6
Nevirapine is continued till 6 weeks for all newborns of HIV infected mothers
Birth weight NVP daily dose 6 ( mg)
NVP daily dose6 ( ml)
< 2000 gms 2 mg/kg once daily 0.2 ml/kg once daily
2000- 2500 gms 10 mg once daily 1 ml once daily
>2500 gms 15 mg once daily 1.5 ml once daily
DELIVERY OF HIV-POSITIVE MOTHER
HIV-positive mother should be delivered by elective LSCS at around 38 weeks before rupture of membranes or onset of labour. Those who conduct the delivery should use universal precautions. Artificial rupture of membranes, invasive procedures like fetal scalp electrodes, fetal blood sampling etc should be avoided. Instrumental delivery should be avoided. Suctioning of newborn with nasogastric tube should be avoided. Baby should be given bath with warm water immediately after delivery to wash off traces of blood and amniotic fluid.2
POSTNATAL PERIOD
Syp. Nevirapine should be given to newborn immediately after delivery and continued till 6 weeks ( more for indicated). If mother opts for exclusive breast feeding, it should be started as with in 1 hour of delivery.
At 6 weeks start cotrimoxazole prophylaxis till 18 months or longer if child is found to be HIV positive. Should do Early Infant Diagnosis at 6 weeks , with Dried blood sample – DNA PCR, viral cultures or P24 antigen detection.
DNA PCR is prepared test to diagnose HIV infection in infants and Children less than 18 months. It is highly sensitive and specific by two weeks of age and performed on peripheral blood mononuclear cells.
Child with EID positive, have to go for ELISA or Western blot at 18 months, if positive start ART irrespective of CD4 count and WHO staging.7
BREAST FEEDING
Breast feeding is associated with a risk of 10 – 15 % for HIV transmission.
Decision for withholding breast feeding should be individualised . According to WHO / NACO guidelines mother can go for Exclusive replacement feeds only if it is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS).2, 4.7
When mother opts for exclusive breast feeding, it should be given till 6 months without mixed feeding because mixed feeding will produce mucosal abrasions in gut facilitating entry of HIV virus.
Mother should take ART regularly when she is breast feeding.
Weaning should be started after 6 months, irrespective of HIV status of baby. If baby is HIV negative breast feeding is stopped at 12 months , 6 weeks after stopping, check HIV status and accordingly take decision regarding starting of ART. If HIV positive ART should be started for child and breast feeding is continued till 2 years.
NUTRITION OF HIV INFECTED CHILDREN
HIV otherwise called as Slims disease is associated with growth faltering.The causes include reduced intake due to poor socioeconomic status or altered caregiving practices, opportunistic infections can also affect food intake, absorbtion and metabolism . studies by WHO proved that HIV infected who are underweight are more likely to die than those who are not malnourished7. HIV infected children has increased requirement of energy, protein and micronutrientas like vitamin C and zinc8.
Good nutritional status is important to maintain health and quality of life in children infected with HIV. Good nutrition can boost immunity and improve the effectiveness of ART30.
MALNUTRITION AND HIV – A VICIOUS CYCLE
Childred with HIV infection having poor nutritional status will have impaired immune system leading to increased vulnerability to infections. Which in turn leads to nutritional needs which goes as a vicious cycle.
WHO suggest that nutritional assessment and support should be an integral part in management of HIV infected children.
Assessment include evaluation of childs growth pattern, appetite, diet and opportunistic infections, these will help in early identification of growth faltering.
Gold standard method for evaluation of nutritional status is anthropometric assessment / auxology2
Anthropometric variables – ht/age, wt/age and wt/ht are classified according to WHO growth charts.
Some children are at increased risk of malnutrition7, they are:
- Childs growth curve shows flattening - Growth curve is dropping downwards - Change in caregiver or home circumstances
- Caretaker reporting lack of weight gain or poor apetite in child
According to WHO,
Cut off Ht/age Wt/Ht Ht/age & Wt/Ht
>mean – 2SD Normal Normal Normal
<mean – 2SD Stunted Wasted Stunted & wasted2
Loss of apetite is the major reason for malnutrition in HIV infected children. Chronic weight loss in HIV/AIDS infected children is often related to gastrointestinal disease and malabsorbtion. In addition to intestinal villi damage caused by HIV, cryptosporidium which is a common opportunistic infection of gut causes malabsorbtion12 .
HIV infected children requires additional amount of calories, to carry out basic metabolic function, for physical activity, for fighting infection and for rebuilding damage tissues. If HIV infected children does not take sufficient calories, fat is broken to provide fuel. If they take more calories than needed extra energy will be stored as fat. Protein deficiency is also closely related to calorie deficiency. Fat in food is a source of high amount of calories, so every HIV positive children below 5 years needs some dietary fat.
Along with the above macronutrients, a balanced diet that contain many micronutrients, organic and inorganic substances are also necessary for normal biological function. Because deficiencies of vitamins and minerals like vitamin A, B-complex, C and E and selenium and zinc which are essential for the immune system to fight against infections are found in children having HIV.Vitamin C, vitamin E, selenium and zinc act as antioxidants that prevent cell damage due free radicals13, 14, 30. Higher intakes of B complexes and vitamin C are associated with slower progression of AIDS in children. Selenium is also important for proper immune function. Its deficiency has been found as an important predictor of mortality due to HIV infection. Iron deficiency anemia is also very prevalent HIV infected children.
Malnutrition in HIV positive children is an outcome of complex inter- related social, economic, political and other issues. Immediate causes of malnutrition in HIV infected children are inadequate dietary intake and opportunistic infections.
Opportunistic infections are associated with increased resting energy expenditure. Kotler at al was the first one to observe the relation between depletion of body cell mass and survival in HIV/AIDS infected children. Suttmann et al proved that loss of body cell mass independently predicts death. Dremaine et al showed that weight loss of 5% over four months is associated with increased risk of opportunistic infections and death. Loss of weight, fat free mass, fat mass and body cell mass significantly predicts mortality among HIV infected children below five years.
In developing countries, micronutrient malnutrition also contributes to weakening of immune system. In HIV positive children nutrition and immunity interacts in two ways. First, HIV induced immunosuppression and opportunistic infections worsen nutritional status. Secondly HIV infection can lead to nutritional deficiencies through malabsorption, decreased food intake and increased utilization of nutrients. Nutritional deficiency reduces immunological response to HIV infection and affects the clinical outcome.
DIETARY INTERVENTIONS IN HIV/AIDS
According to the guidelines HIV infected children require 10% more energy than uninfected children even if asymptomatic. Caregivers should be educated about the extra nutritional requirements of the children and about nutritional value of different food.
Micronutrients should be supplemented and should be provided at a value equivalent to one Recommended Daily Allowance. Micronutrient deficiency will impair immune system and increase susceptibility to infection. The infected children benefit from high dose of vitamin A since it is very important for immune function. It reduces all cause mortality and diarrhoeal morbidity. The dose is same as that given to uninfected peers.
Diet rich in B complex and vitamin C should be added in diet as it will slow the progression of the disease. Good source of niacin include yeast, meat, poultry, fish, legumes etc will make immune system stronger. Zinc supplementation along the oral rehydration should be given for treatment of diarrhoea. Zinc supplementation reduces complications from diarrhoea and pneumonia and also improves immune system.
Zinc supplementation should be in the same way as uninfected children.
Some fatty acids like omega – 3- fatty acids that are seen in fish oils are needed to reduce the impact of cytokines – interleukine 1 and tumour necrosis factor . Deworming should be done every 6 months.
If there is growth faltering the cause should be identified and managed . The factors that interfere with food intake and digestion like aphthous ulcers, oral thrush, diarrhoea etc should be treated immediately. During opportunistic infection, energy intake should be increased by 20 – 30%5, 7.
Significant weight loss is seen particularly with tuberculosis and diarrhoeal disease. Extra calories can be given by increasing energy density of family foods and also by increasing the quantity of food consumed.
Child should be given mashed food or chopped food with sauce in case of mouth ulcers and cooked fruits and vegetables rather than raw items in case of diarrhoea.
HIV infected children with severe malnutrition are at higher risk of mortality than uninfected children with severe malnutrition. During the periods of severe malnutrition and following the periods, energy supplementation should be increased by 50 – 100% in order to recover the weight. The treatment of severe malnutrition should be in the same way as that of uninfected children.
Successful viral suppression and immune reconstitution with ART can reverse the weight loss and improves the linear growth.
Additional energy requirement in HIV infected children7:
Asymptomatic, adequate growth
Poor weight gain, increased nutritional needs
Severely malnourished
10% extra 20-30% extra 50-100% extra 6-11 months
Calories
needed extra 60-70kcal/day 120-150 kcal/day 150-220 kcal/kg/day Ways to
increase the energy by adding extra
meals
Add 2 tsp of edible oil
& 1 tsp of sugar to porridge in addition to
normal diet
Add 2 tsp of edible oil & 1-2 tsp of sugar to porridge .
to add 2 times daily
Therapeutic feeding as per
national guidelines
12-23 months
Extra calories 80-90 kcal/ day 160- 190 kcal/day 150-220 kcal/kg /day Ways to
increase energy by adding extra
meals
Add 2 tsp of edible oil
& 2 tsp of sugar to porridge
Extra cup (200 ml) of full cream milk with 1 tsp of sugar
Therapeutic feeding as per
national guidelines
2- 5 years
Extra calories 100-140 kcal/day 200-280 kcal/day 150- 220 kcal/kg/day Ways to
increase energy in addition to
meals
Extra cup of milk/
sweetened curd
2 puris with vegetables
Therapeutic feeding as per
national guidelines.
TREATMENT OF PAEDIATRIC HIV Goals of treatment are:
- Reduce mortality and morbidity due to HIV - To restore the immunity
- To suppress viral replication - Minimize drug toxicity
- Maintain normal physical growth and neurocognitive development - Improve quality of life
Classes of antiretroviral drugs used are 6,7
- Nucleoside / nucleotide reverse transcriptase inhibitors - Protease inhibitors
- Non nucleoside reverse transcriptase inhibitors - Fusion inhibitors
- CCR5 co-receptor antagonist - HIV integrase inhibitors
Initiation of ART therapy:
For children <2 year of age to start therapy as soon as diagnosis is made irrespective of CD4 count
For children of age 24 – 59 months, start ART when CD4 < 25% or count
<750/cu.mm
For children > 60 months start treatment when CD4 count is < 350/ cu.mm
Paediatric ART regimen:
First line therapy in children < 24 months with no exposure to nevirapine:
2 NRTI ( zidovudine & lamivudine) + NVP
First line therapy in children in children < 24 months with exposure to NVP:
2 NRTI + protease inhibitor ( ritonavir/ lopinavir) First line therapy for children > 24 months : 2 NRTI + 1 NNRTI
MATERIALS AND METHADOLOGY
The study was done to assess the nutritional status of HIV infected children less than 5 years and find out various factors that affect the nutritional status in ART centre, Salem
SOURCE OF DATA:
55 children who are HIV infected and less than 5 years who visit ART centre, Government Mohan Kumaramangalam Medical College, Salem were included in the study as per inclusion and exclusion criteria .Their dietary pattern and nutritional status along with laboratory investigations for assessing nutritional deficiencies were done .
STUDY DESIGN:
It is a cross-sectional study of HIV infected children less than 5 years visiting our ART centre.
INCLUSION CRITERIA:
All HIV infected children visiting our ART centre, less than 5 years of age were eligible for the study.
EXCLUSION CRITERIA:
Children of caretakers who did not give consent for the study were excluded from the study.
ETHICAL CONSIDERATIONS:
Ethical clearance committee clearance was obtained and permission to proceed with the study was obtained from ART centre, Salem
METHOD OF COLLECTION OF DATA:
All the children who are attending Salem ART centre for regular follow up and less than 5 years were taken up for the study. Caretakers were informed about the study and informed written consent was obtained.
Ethical committee clearance was obtained.
— A detailed questionnaire was used covering information regarding children and caretakers, socioeconomic status, food consumption pattern, 24 hr dietary pattern & nutritional knowledge. This type of questionnaire is a restricted form that calls for a yes / no answers or short responses. The questionnaire also included a consent form signed by guardian.
— Dietary assessment data was collected using 24 hrs dietary recall method
— All these children were clinically evaluated to look for the presence of features of respiratory tract infection, gastroenteritis, oral thrush or aphthous ulcers, tuberculosis etc
— Physical growth indices, height for age, weight for age, weight for height and mid upper arm circumference were calculated to describe children’s nutritional status in comparison to WHO standard.
Height was measured using stadiometer board with precision of 0.1 cm for children more than 2 years of age. For children less than 2 years of age infantometer is used to measure the length
Weight was measured using electronic weighing machine.
Mid upper arm circumference was measured with non stretchable measuring tape.and Shakir’s Tape.
Anthropometric parameters weight for height, height for age and weight for age were compared with WHO growth chart and classified.
Mid-upper arm circumference > 13.5 was considered as normal, between 12.5 and 13.5 as moderate malnutrition and < 12.5 cm as severe malnutrition.
Blood samples were sent to the laboratory to look for the evidence of anemia, protein deficiency and deficiencies of micronutrients- iron, zinc, calcium.
RESULTS:
A total of 55 children attending Salem ART centre less than 5 years of age were included in the study as per inclusion and exclusion criteria laid down and their nutritional assessment was done along with assessment of factors affecting the nutritition.
SOCIAL FACTORS:
N %
Male 29 52.73
Gender of child
Female 26 47.27
< 25 11 20.00 26 - 49 33 60.00 Age in yrs
> 50 11 20.00
Male 7 12.73
Gender of caretaker
Female 48 87.27
Unmarried 1 1.82
Divorcee 7 12.73 Married 35 63.64 Marital status of caretaker
Widowed 12 21.82
Uneducated 9 16.36 Primary 20 36.36 Secondary 18 32.73 Educational status of caretaker
Tertiary 8 14.55
Cooley 20 36.36
Salaried 12 21.82 Occupation
Unemployed 23 41.82
Total 55 100.00
The study showed that over half of the children (52.73%) were boys while 47.27 % were girls. The study showed that highest percentage of caretakers were between 26 to 49 years of age . Age group < 25 years and > 50 years both occupied 20% each. Majority of caretakers ( 87.27%) were females were as male caretakers occupied only 12.73%. Majority of caretakers were married (63.64%), while 21.82% were widowed, 12.73% were divorcees and remaining 1.82% were unmarried. 41.82% of caretakers were unemployed, 36.36% were cooleys and 21.82% were salaried.
N %
Aunt 6 10.91
Father 6 10.91
Mother 36 65.45
Grand father 1 1.82 Relation of caretaker
Grand mother 6 10.91
The study showed that majority of children were mainly looked after by their mothers (65.45%), father, aunts and grandmothers occupied 10.91% of caretakers each, grandfathers were caretaker in 1.82%.
NUTRITIONAL KNOWLEDGE OF CARETAKERS:
It was found that more than 50% of care takers of HIV infected children in the study didn’t have nutritional knowledge.
Only 45% of care takers had nutritional knowledge.
Yes 25 45.45 Nutrition knowledge
No 30 54.55
NUTRITIONAL KNOWLEDGE OF CARETAKERS:
PERCENTAGE OF CALORIE AND PROTEIN DEFICIENCIES DISTRIBUTED AMONG THE CHILDREN:
< 25% 11 20.00
25 – 50% 34 61.82
% of calorie deficiency
> 50% 10 18.18
< 25% 16 29.09
25 – 50% 29 52.73
% of protein deficiency
> 50% 10 18.18
PERCENTAGE OF CALORIE AND PROTEIN DEFICIENCIES DISTRIBUTED AMONG THE CHILDREN:
Series 1 represent calorie deficiency and series 2 represent protein deficiency.
Study showed majority of children had 25- 50 % deficiency of calories and proteins from the required followed by <25% deficiency and then 18.18 % had deficiency more than 50% of the required.
DISTRIBUTION OF ANTHROPOMETRIC PARAMETERS AMONG THE CHILDREN:
MID UPPER ARM CIRCUMFERANCE:
< 12.5 28 50.91
12.5 - 13.5 21 38.18 MAC
> 13.5 6 10.91
The study showed that more than half (50.91%) of children had MAC <
12.5 cm showing severe malnutrition, 38.18% had between 12.5 – 13.5 cms showing moderate malnutrition and 10.91% had MAC > 13.5 cms showing normal nutritional status.
MID UPPER ARM CIRCUMFERANCE:
The pie chart shows that more than half (50.91%) of children had MAC <
12.5 cm showing severe malnutrition.
DISTRIBUTION OF WEIGHT/AGE,HEIGHT/AGE AND WEIGHT / HEIGHT
N <1SD-2SD < 2SD
N % N % N %
Total
wt/age 6 10.9 21 38.2 28 50.9 55
ht/age 11 20.0 23 41.8 21 38.2 55
wt/ht 8 14.5 26 47.3 21 38.2 55
The study showed that wt/age was < 2SD in more than half of the cases (50.9%) where as 38.2% had wt/age between < 1SD – 2SD and 10.9% had wt/age in normal range. Ht/age was < 1SD -2SD in 41.8% of cases, was < 2SD in 38.2%
of cases and within normal range for 20% of cases. Wt/ht was <1SD – 2SD in 47.3% of cases, < 2SD in 38.2% of cases and within normal range in 14.5 % of cases.
GRAPH SHOWING DISTRIBUTION OF WT/AGE, HT/AGE AND WT/HT:
PREVALANCE OF OTHER ILLNESS THAT AFFECT THE NUTRITION:
Prevalence of nutrition related diseases N %
Nil 9 16.36
LRI 13 23.64
AGE 4 7.27
LRI, AGE 9 16.36
Fever 3 5.45
Aphthous ulcer 3 5.45
AGE, aphthous ulcers 2 3.64
LRI, aphthous ulcers 1 1.82
Oral thrush, LRI 5 9.09
Pul.TB 5 9.09
URI, AGE 1 1.82
About 23.64% of the children were suffering from LRI, 16.36% had both AGE and LRI, 16.36% of children didn’t have any associated morbidities . 9 % of children suffered from pulmonary TB. Another 9% suffered from LRI and aphthous ulcers. 7.27% of the children suffered from AGE alone . 5.45 % of children suffered from fever with no obvious focus, another 5.45% had aphthous ulcers. AGE with aphthous ulcers were found in 3.64% of children. 1.82 % of children had LRI and aphthous ulcers and another 1.82% had URI and AGE. All these factors caused significant reduction in nutrition after the onset of illness.
PREVALANCE OF OTHER ILLNESS THAT AFFECT THE NUTRITION
IMMUNISATION STATUS OF CHILDREN
NK 5 9.09
Complete 34 61.82 Immunization
Incomplete 16 29.09
More than half of children ( 61.82%) had immunisation appropriate for age, 29.09% had incomplete immunisation status and for 9.09% of caretakers didn’t have any idea regarding the immunisation status.
IMMUNISATION STATUS OF CHILDREN
The Bar diagram shows that more than half of children ( 61.82%) had immunisation appropriate for age.
ART INTAKE:
Regular 39 70.91
ART intake
Irregular 16 29.09
70.91% of children took their ART regularly, remaining were 29% on irregular treatment.
70.91% of children took their ART regularly, remaining were 29% on irregular treatment.
PREVALENCE OF ANEMIA AND DISTRIBUTION OF SEVERITY OF ANEMIA AMONG THE CHILDREN:
No 5 9.09
Mild 18 32.73
Moderate 15 27.27
Anemia
Severe 17 30.91
PREVALENCE OF ANEMIA AND DISTRIBUTION OF SEVERITY OF ANEMIA AMONG THE CHILDREN:
Majority of children ( 32.73%) suffered from mild anemia, 27.27 % of children had moderate anemia and 30.91% had severe anemia. Peripheral smear picture were suggestive of microcytic hypochromic anemia. 9.09% of children had normal haemoglobin levels and peripheral smear picture was normal
THE PATTERN OF DISTRIBUTION OF PROTEIN AND MICRONUTRIENT DEFICIENCIES:
Normal Decreased
N % N %
Total
S.Proteins 35 63.64 20 36.36 55
S.Iron 20 36.36 35 63.64 55
S. Zinc 21 38.18 34 61.82 55 S. Cholesterol 12 21.82 43 78.18 55 S. Calcium 26 47.27 29 52.73 55
THE PATTERN OF DISTRIBUTION OF PROTEIN AND MICRONUTRIENT DEFICIENCIES:
The study showed that serum proteins were normal in 63.64 % cases, but was decreased in 36.36% cases, serum iron was normal in 36.36% cases and was decreased in 63.64% cases. Serum zinc was normal in 38.18 % cases, and was decreased in 61.82% cases. Serum cholesterol was normal in 21.82% cases and was decreased in 78.18% of cases. Serum calcium was normal in 47.27% cases and was normal in 52.73% of cases.
RELATIONSHIP BETWEEN NUTRITITIONAL KNOWLEDGE AND ANTHROPOMETRIC PARAMETERS:
Nutrition knowledge Yes No N % N %
Total Chi square p
N 5 83.3 1 16.7 6
<1SD-2SD 15 71.4 6 28.6 21 wt/age
< 2SD 5 17.9 23 82.1 28
17.79 < 0.001**
N 7 63.6 4 36.4 11
<1SD-2SD 16 69.6 7 30.4 23 ht/age
< 2SD 2 9.5 19 90.5 21
17.79 < 0.001**
N 6 75.0 2 25.0 8
<1SD-2SD 17 65.4 9 34.6 26 wt/ht
< 2SD 2 9.5 19 90.5 21
17.92 < 0.001**
Total 25 45.5 30 54.5 55
RELATIONSHIP BETWEEN NUTRITITIONAL KNOWLEDGE AND ANTHROPOMETRIC PARAMETERS:
The study showed that there is significant relation between nutritional knowledge of caretakers and nutritional status of children. More than three-fourth of children children with normal wt/age (83.3%) had their caretakers with good nutritional knowledge, 71.4% of children with wt/age < 1SD- 2SD belonged to this group and of the total children with wt/age < 2 SD, only 17.9% had their caretakers with nutritional knowledge.
Evaluation of ht/age showed that of the total children with normal ht/age, 63.6% belonged to the children of caretakers with nutritional knowledge, 69.6% of those with ht/age <1SD – 2SD belongs to this group. Only 9.5% of those with ht/age < 2SD had their caretakers with nutritional knowledge.
Evaluation of distribution of wt/ht showed that 75% of children with normal range had their caretakers with nutritional knowledge, 65.4% of children with value < 1SD – 2SD belongs this group and only 9.5% of children with wt/ht
< 2SD had their parents with nutritional knowledge
RELATION BETWEEN ANEMIA AND NUTRITIONAL KNOWLEDGE OF CARETAKER:
Anemia
No Mild Moderate Severe Nutrition
knowledge
N % N % N % N %
Total Chi square p
Yes 4 16.0 14 56.0 5 20.0 2 8.0 25 No 1 3.3 4 13.3 10 33.3 15 50.0 30
18.66
Total 5 9.1 18 32.7 15 27.3 17 30.9 55
RELATION BETWEEN ANEMIA AND NUTRITIONAL KNOWLEDGE OF CARETAKER:
Of the total children with caretakers having nutritional knowledge, 16%
had no anemia, 56% had mild anemia, 20 % had moderate anemia and only 8%
had sever anemia.
While of the children of caretakers with no nutritional knowledge, only 3.3% had no anemia, 13.3% had mild anemia, 33.3% had moderate anemia and half of the children had severe anemia.
RELATION BETWEEN IMMUNIZATION AND NUTRITIONAL STATUS:
Immunization
NK Complete Incomplete N % N % N %
Total Chi
square p
N 6 100.0 6
<1SD-
2SD 1 4.8 15 71.4 5 23.8 21 wt/age
< 2SD 4 14.3 13 46.4 11 39.3 28
7.56 0.109
N 1 9.1 10 90.9 11
<1SD-
2SD 15 65.2 8 34.8 23
ht/age
< 2SD 4 19.0 9 42.9 8 38.1 21
11.19 0.024*
N 8 100.0 8
<1SD-
2SD 2 7.7 17 65.4 7 26.9 26 wt/ht
< 2SD 3 14.3 9 42.9 9 42.9 21
8.31 0.081
Total 5 9.1 34 61.8 16 29.1 55
In all children with normal wt/age and wt/ht their immunization status was found to be complete. In children with normal ht/age, 90.9% was found to be fully immunized and for the remaining immunization status was not known. But in children with these anthropometric parameters < 2SD, majority of them were found to be fully immunized.
RELATION BETWEEN REGULARITY OF ART INTAKE AND NUTRITIONAL STATUS:
ART intake Regular Irregular
N % N %
Total Chi square p
N 6 100.0 6
<1SD-2SD 18 85.7 3 14.3 21 wt/age
< 2SD 15 53.6 13 46.4 28
8.77 0.012*
N 10 90.9 1 9.1 11
<1SD-2SD 18 78.3 5 21.7 23 ht/age
< 2SD 11 52.4 10 47.6 21
6.23 0.044*
N 8 100.0 8
<1SD-2SD 21 80.8 5 19.2 26 wt/ht
< 2SD 10 47.6 11 52.4 21
10.03 0.007**
Total 39 70.9 16 29.1 55
All the children with normal wt/age and wt/ht were found to be taking ART regularly and 90.9% of children with normal wt/ht took medications regularly.85.7% of children with wt/age <1SD – 2SD, 78.3% of children with ht/age < 1SD – 2SD and 80.8% of children with wt/ht < 1SD- 2SD took ART regularly. But among children with wt/age < 2SD, 53.6% took ART regularly, among children with ht/age < 2SD 52.4% took ART regularly and among children with wt/ht < 2SD 47.6% took ART regularly.
DISCUSSION:
HIV/AIDS has emerged as one of the pandemic. This disease has devastating effects on childs health and nutritional status. Nutritition of children <
5 years suffering from HIV/AIDS is an important determining factor of the morbidity and mortality of the children. Regular ART intake and proper follow up of these children also improves the quality of life.
In our study, conducted using 55 children attending Salem ART centre, more than half of the children were boys. The children were mainly looked after by female caretakers ( 87.27%), mainly mothers were the caretakers and majority of these caretakers belonged to age group 26 to 49 years. Majority of these caretakers had only primary education ( 36.36%) and 16.36% were uneducated.
Majority of caretakers were unemployed ( 41.82%) and another 36.36% were cooleys. These social factors proved that majority of the children were coming from poor socioeconomic categories.
In a similar study done by Ali Duale Jama8 ,similarly majority of children were boys with majority of the caretakers ( 87.5%) being females, 44% of caretakers had only primary education and majority of them were farmers.
Caretakers nutritional knowledge were assessed by distributing questionnaire which asked them what is their concept regarding composition of good nutritional diet, whether they know the outcome of poor nutritional status and whether they know that the child requires extra nutrition due to the illness and it was found that more than half of the caretakers ( 54.55%) didn’t have nutritional knowledge. Similarly in the study by Ali Duale Jama > 50% didn’t have nutritional knowledge8
Using 24 hrs recall method percentage of calorie and protein deficiencies were calculated and it was found that more than half of the children had 24 – 49%
calorie and protein deficiencies in their diet and 18.18% had > 50% deficiency in both proteins and calories
On doing anthropometric assessment, more than half of the children were found to be having MAC < 12.5 suggestive of severe malnutrition . More than half of the children had wt/age < 2SD below the mean suggestive of underweight, majority of ( 41.8%) children had ht/age < 1SD – 2SD and 38.2% had stunting .majority of children ( 47.3%) had wt/ht < 1SD – 2SD and 38.2% had wasting. In the study by Ali Duale Jame only 13.5% had wt/age < 2 SD, 11.3 % had ht/age <
2 SD and 12.1% had wt/ht < 2 SD8. In the study 63% had normal nutritional status. In another study by Berkley at all showed that 25% had wt/ht < 2 SD59.
Only 16.36% of children were found to be not suffering from associated morbidities that will interfere with the nutritional status and majority were found to be suffering from LRI.
Immunization status was appropriate for age in more than half of the cases and ART was taken regularly in nearly half of the cases .
Majority of children had mild anemia, but almost 30% had severe anemia and only 9 % had no anemia
Serum iron, zinc and calcium were found to be decreased in more than half of the cases. Similar study by Wafaie etal showed significant number of HIV infected children having zinc and other micronutrient deficiency60.
From the study a positive correlation was found between nutritional status and nutritional knowledge of caretakers.It was found that wt/age was normal for more than three- fourth of the cases (83.3%) among the children of caretakers with nutritional knowledge and only 17.9% had wt/age < 2SD. Ht/age was normal in around 63 % of these children and stunting was seen in < 10 % of children with caretakers having nutritional knowledge . Three-fourth of the cases had wt/ht normal and only less than 10 % had wasting among the children of caretakers with good nutritional knowledge.
Anemia was also found to be related to the nutritional knowledge, 16% of children of caretakers with good nutritional knowledge had no anemia and majority of children belonging to this group had only mild anemia( 56%). Among children of caretakers with no nutritional knowledge half the children were found to have severe anemia.
While assessing the relation between ART intake and nutritional status it was found that all the children with normal range of wt/age and ht/age belonged to the group regularly taking ART. More than 90% of children with normal range of ht/age regularly took ART.But among the group having wt/age and ht/age < 2SD, more than 50% regularly took ART and 47% of children with wasting also took ART regularly.
IMPROVEMENT OF NUTRITIONAL STATUS OF HIV INFECTED CHILDREN:
Malnutrition in HIV infected children can be controlled to a limit with the help of proper and additional nutrient supplementation which needs much alteration in the social condition of the child and also nutritional knowledge of the caretakers.
Along with ensuring that the child is regularly taking ART, child should be examined for other comorbid illness and managed immediately, since majority of the children are found to be having some other associated illness and this will alter their nutritional intake and also increase their nutritional requirements.
During each follow up, the nutritional intake of child should be assessed for the adequacy and caretakers should be counselled regarding the importance of nutrition and simple, cheap and effective methods to improve the nutritional quality of childs diet.
Micronutrients like iron, calcium, zinc and vitamin A, B complex and vitamin C also should be supplemented during the follow up since these measures help to boost the immunity.
It should be made sure that they get regular immunization, even the live vaccines if they are not symptomatic.
