4.1. Malnutrition
Malnutrition is a common condition in HIV-infected children and is a major contributor to mortality. In HIV-infected children, wasting (i.e. very low weight for height/length) is very common and has been associated with shorter child survival.
Severe Acute Malnutrition (SAM)
Severe acute malnutrition develops when the child is not getting enough energy or protein and other nutrients from his food to meet his nutritional needs. A child who has had frequent illnesses, HIV infection, or tuberculosis can also develop severe acute malnutrition. The child's appetite decreases, and the food that the child eats is not used efficiently. A child with severe acute malnutrition may present with severe wasting and/or bilateral oedema (swelling of both feet).
Use IMCI criteria:
For all children:
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Determine weight-for-age
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Look for oedema of both feet
If age up to 6 month:
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Look for visible severe wasting
If age 6 months or above:
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Determine if mid-upper arm circumference (MUAC) less than 11 cm
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If MUAC less than 11 cm, or oedema, assess appetite
Optimal growth of an infant or child, measured in weight and height/length, is a sensitive indicator of HIV disease progression. Severe growth problems in HIV-infected children that are not attributed to inadequate nutritional intake instead point to the need for ART initiation (i.e. growth failure and severe malnutrition/wasting are used as criteria for clinical stage 3 and 4 disease, respectively). Growth is also useful when evaluating the child's response to ART; the potential adverse effects of ARV drugs or opportunistic infections may affect food intake and nutrition in general, resulting in limited growth improvements and/or adherence to therapy.
4.1.1. Nutritional assessment and support
All HIV-infected infants and children should be assessed for nutritional status including weight-for-height, height-for-age, and weight-for-age. Where these cannot be measured, MUAC could be measured to decide nutritional status. As for all infants, HIV-infected infants should be weighed and length measured monthly for the first five years of life, and standardized growth curves used to determine the nutritional status. Thereafter, children should be weighed at each review and full nutritional assessments made every three months, unless the child requires particular attention because of growth problems or special nutritional requirements.
HIV infection is associated with increased energy needs, which requires a proactive approach to nutritional support in HIV-infected children:
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In asymptomatic HIV-infected children, resting energy expenditure is increased by about 10%
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In HIV-infected children experiencing growth failure, energy expenditure is increased between 50% and 100%
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It is recommended to increase the energy intake of HIV-infected infants and children—if they are asymptomatic, by 10% of the RDA for their age and sex, and if they are symptomatic or recovering from acute infections, by 20–30% of the RDA.
Vitamin A supplements should be given in accordance with the WHO-recommended high-dose prevention schedule for children at high risk of vitamin A deficiency.
Identifying the underlying cause of growth failure may provide valuable information on further support strategies. This may include: treating underlying illness (common illnesses should be managed according to IMCI guidelines), evaluating the need to start or switch ART, family education about locally available food choices, and referral to food programmes, preferably with support for the whole family. In addition, selecting specific high-energy, palatable foods for children with conditions that interfere with normal ingestion or digestion (e.g. sore throat or mouth, oral thrush, diarrhoea) may both alleviate symptoms and ensure sufficient energy intake.
4.1.2. ART in severely malnourished children
All children with severe malnutrition are at risk for a number of life-threatening problems and urgently require therapeutic feeding. It is not known at what phase of malnutrition treatment ART should start. Expert opinion therefore suggests that HIV-infected children with severe malnutrition should be stabilized before decisions are made on initiating ART. The initial treatment of severe malnutrition lasts until children have stabilized on this treatment, and their appetites have returned. In HIV-uninfected children the response to initial treatment of severe malnutrition should not take longer than 10 days, but in HIV-infected children the response may be delayed or very limited.
ART is indicated in HIV-infected infants and children by
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unexplained severe malnutrition that is not caused by an untreated opportunistic infection
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lack of response to standard nutritional therapy (i.e. clinical stage 4 disease)
In children who rapidly gain weight because of adequate nutrition and ART, ARV dosages should be frequently reviewed (see Annex E). The recurrence of severe malnutrition that is not caused by a lack of food in children receiving ART may indicate treatment failure and the need to switch therapy.
4.2. Anaemia
Aneamia occurs in 20 – 70% of HIV-infected children, and more commonly in children with AIDS. Anaemia results from a number of underlying causes.
Definition:
Anaemia can be defined as a reduction in red blood cell mass or blood haemoglobin concentration. In practice, anaemia is most commonly defined by reductions in one or more of the following:
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Chronic infection and diseases (including HIV Infection)
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Poor nutrition
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Autoimmune diseases
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Virus associated conditions (e.g. parvovirus B19 red cell aplasia)
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Adverse drug effects blood loss, especially chronic blood loss, through intestinal hookworm infection haemolysis caused by many conditions, including bacterial infections and malaria
History:
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Patients with inherited aetiologies often present in childhood and may have a positive family history.
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Severity and initiation of symptoms:
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Patients with chronic anaemia may not be as symptomatic as patients with acute anaemia with similar haemoglobin values.
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Prior episodes of anaemia may indicate inherited forms, whereas anaemia in a patient with previously documented normal blood counts suggests an acquired aetiology.
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Questions relating to haemolytic episodes:
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Changes in urine colour, sclera icterus, or jaundice associated with the symptoms of anaemia should be asked.
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Questions about possible blood loss:
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Bleeding from the gastrointestinal tract should be reviewed, including changes in stool colour, identifying blood in stools, and history of bowel symptoms.
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Teenagers may have excessive menstrual losses without realizing it
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Common causes of anaemia in children living in low- and middle-income countries are the presence of intestinal nematode infection (e.g., hookworm, whipworm leading to iron deficient anaemia) and malaria leading to haemolytic anaemia.
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Underlying medical conditions: a careful past medical history and review of symptoms should be obtained to elucidate chronic underlying infectious or inflammatory conditions that may result in anaemia.
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Prior drug or toxin exposure
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Questions relating to diet: questions should be primarily aimed at determining iron content in the diet and, to a lesser degree, folate and B12 content. Document the type of diet, type of formula (if iron fortified), and age of infant at the time of discontinuing formula or breast milk. In addition, determine the amount and type of milk the patient is drinking. Specific questions about if the child has symptoms consistent with pica may help to diagnose lead poisoning.
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Birth history: A birth and neonatal history should be obtained, including: infant and mother's blood type, any history of exchange or intrauterine transfusion, and a history of anaemia in the early neonatal period. Gestational age at birth is important, as premature infants may have iron or vitamin E deficiencies that result in anaemia. The presence of jaundice or need for phototherapy may signify the presence of an inherited haemolytic anaemia.
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Developmental milestones: parents should be asked questions to determine if the child has reached age-appropriate developmental milestones. Loss of milestones or developmental delay in infants with megaloblastic anaemia may signify abnormalities in the cobalamin, B12, pathway.
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Family history, race, and ethnicity: any family history of anaemia should be pursued in depth.
Symptoms
Few clinical disturbances occur until the haemoglobin level falls below 7 – 8 g/dl. Below this level pallor becomes obvious in the skin and mucous membranes. Physiologic adjustments include increased cardiac output, increased oxygen extraction, and shunting of blood towards vital organs and tissues.
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Common symptoms of anaemia include lethargy, tachycardia, and pallor.
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Acutely anaemic infants may present with irritability and poor oral intake. In contrast, patients with chronic anaemia may be well compensated and may not have significant complaints.
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Weakness, tachycardia, shortness of breath on exertion ultimately result from increasingly severe anaemia, regardless of the cause.
Signs
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Pallor mucus membranes and hands
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Tachycardia
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Tachypnoea
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Signs of respiratory distress
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Signs of congestive cardiac failure
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Jaundice and Hepatosplenomegaly: in patients with haemolytic processes.
Investigations
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Full Blood Count (FBC) and blood smear
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Reticulocyte count:
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An evaluation of the reticulocyte count aids in defining the aetiology of the anaemia.
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An increased reticulocyte count generally is seen as a normal bone marrow response to ongoing hemolysis or nonchronic blood loss.
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A low reticulocyte count, which reflects decreased production of red blood cells, is more consistent with bone marrow depression.
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Bone marrow biopsy
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Investigation and management should address both the cause and etiology of aneamia
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Is anaemia associated with other haematological abnormalities such as Aplastic Anaemia and Leukaemia? If yes, review blood cell indices and bone marrow smear.
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Is it associated with reticulocytosis? If yes usually a consequence of bleeding or ongoing haemolysis?
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Is there associated hyperbilirubinaemia? If yes, usually due to haemolysis.
Review peripheral blood smear
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Is anaemia associated with a lower than appropriate reticulocyte response? If yes: assess red blood cell size
Below you will find tables on pages 40 -41 on investigation and management of anaemia, neutropenia and thrombocytopenia
Common causes and etiology of anemia related to HIV infection can be found below
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| Cause of Anemia | Etiology |
|---|
| Poor production of RBCs | HIV infection
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Anemia of chronic disease - ◦
HIV infection of stromal cells
Infection
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CMV, Parvovirus B19, atypical tuberculosis
Malignancy
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Lymphoma, Kaposi's sarcoma
Drugs
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Sulfonamides, dapsone
|
| Destruction of RBCs | Hemophagocytic syndrome
Disseminated intravascular coagulation (DIC)
Drug associated hemolytic anemia |
| Ineffective Production of RBCs | Folate and iron deficiency
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Dietary - ◦
Intestinal malabsorption
Vitamin B-12 deficiency
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Intestinal malabsorption - ◦
Infection in stomach or intestine
|
Causes and etiology of neutropenia related to HIV infection
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| Causes of Neutropenia | Etiology |
|---|
| Decreased WBC growth factors | Decreased numbers of progenitor cells in the bone marrow
Decreased numbers of granulocytes and monocytes
Decreased serum levels of GCSF
Decreased numbers of neutrophils |
| Drugs | Antiretrovirals: ZDV, 3TC, ddI, d4T
Anti-viral agents: gancyclovir, foscarnet
Anti-fungal agents: flucytosine, amphotericin
Pneumocystis carinii prophylaxis: sulfanomides, trimethoprim, pentamidine
Antineoplastic agents: doxorubicin, cyclophosphamide, methotrexate, cytarabine |
Guides for managing anaemia, neutropenia and thrombocytopenia
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Anaemia
(Haemoglobin <10 gm/dL) | Monitor CBC for decreased haemoglobin
Assess for tachycardia, heart murmur, pallor, tachypnoea, dyspnoea, level of consciousness
Monitor for associated symptoms; irritability, fatigue, shortness of breath, chest pain with exertion, headaches
Provide medical interventions as ordered
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Transfuse with PRBCs 10 ml/kg prn when symptomatic - -
Provide oxygen during periods of respiratory distress
Patient and family education
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Quiet activities are more well tolerated during periods of anaemia - -
Signs and symptoms that signal anaemia: irritability, change in skin colour, increased heart rate and respirations, shortness of breath
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Neutropenia
(ANC < 1000/mm3 for 2 wks. to 1 yr. of age)
(ANC < 1500/mm3 for children > 1 yr.) | Monitor CBC for decreased WBC count and ANC
Assess for fever, skin ulcerations, pain, cough, tachypnoea, rales, wheezing, stomatitis, perirectal fissures
Provide antibiotic therapy as ordered for fever >38.4°C
Monitor temperature
NO rectal temperatures or exams
Avoid intramuscular injections
Avoid urinary catheterization
Prep skin with povidone-iodine or alcohol prior to phlebotomy
Patient and family education
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Avoid ill contacts - -
Wash hands frequently - -
Notify healthcare provider when fever is >38.4°C - -
Practice meticulous oral hygiene
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Thrombocytopenia
(Platelet count < 100,000/ mm3) | Monitor CBC for decreased platelet count
Assess for bleeding, bruising, petechiae, purpura
Provide medical interventions as ordered
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Transfuse platelets 6 units/m2 prn for active bleeding that is not controlled
Avoid intramuscular injections or lumbar puncture if possible
Use pressure dressings if bone marrow aspiration is necessary
NO rectal temperatures of exams
Patient and family education
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Quiet activities help prevent bleeding associated with injury - -
Encourage fluids to prevent constipation - -
Notify healthcare provider if bleeding occurs and cannot be controlled
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