Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection Managing Complications of

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Guidelines for theUse of Antiretroviral
Agentsin Pediatric HIV Infection Managing
Complications of HIV Infection inHIV-Infected
Children on Antiretroviral TherapyNutritional
Care
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About This Presentation

• These slides were developed using the March 2005
  Pediatric Guidelines. The intended audience is
  clinicians involved in the care of patients with
  HIV.
• Users are cautioned that, because of the rapidly
  changing field of HIV care, this information
  could become out of date quickly. Finally, it is
  intended that these slides be used as prepared,
  without changes in either content or attribution.
  Users are asked to honor this intent.
• AETC NRC
• http//www.aids-etc.org

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Introduction

• Malnutrition impairs immune function
• HIV-related nutrient malabsorption compromises
  nutritional status
• Nutritional deficiencies may begin early in HIV
  infection

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Introduction (2)

• In HIV-infected children, immune status and HIV
  viral load may predict growth outcomes
• ART may improve growth outcomes, though data are
  variable
• Growth failure, especially height failure, is
  associated with HIV treatment failure and disease
  progression

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Introduction (3)

• In the United States, nutritional problems in
  children remain common
• High prevalence of growth failure
• Wasting syndrome in 18 in 2000 (CDC)
• New and emerging nutritional problems
• Overweight or at risk (BMI gt85)
• Metabolic complications of ART (lipodystrophy,
  insulin resistance)

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Assessment

• Monitor growth regularly
• Height, weight, head circumference, BMI (2-20
  years)
• Plot on CDC growth curves
• Investigate deviation from growth curve
• Evaluate clinical status, including
• Symptoms that might impair nutritional
  status(eg, pain, GI losses, acute illness)
• Physical activity, food intake, food availability
• Signs/symptoms of vitamin or micronutrient
  deficiency

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Assessment (2)

• Laboratory tests albumin, prealbumin,
  transferrin, Hct, Hgb, lipid panel, liver
  transaminases, HIV markers
• Consult nutritionist

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Assessment (3)

• Evaluate diet
• Vitamin B12, E, and A beta-carotene (deficiency
  associated with HIV progression in adults)
• Iron, carnitine, vitamin A deficiency (important
  for immune function)
• Zinc, selenium
• Vitamin D, calcium(abnormal bone mineralization
  in HIV-infected children)

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AIDS Wasting

• CDC definition
• Persistent weight loss gt10 of baseline
• OR
• Downward shift of 2 percentile line on CDC
  weight-for-age chart (for age 1 year)
• OR
• lt5th percentile on weight-for-age chart(2
  measurements 30 days apart) plus chronic
  diarrhea or fever 30 days
• If possible, intervene before child has wasting
  syndrome

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Prevention of Weight Abnormalities

• Specific macronutrient and micronutrient
  requirements for HIV-infected children are
  unknown
• For asymptomatic children, emphasize varied,
  nutrient-dense diet to maintain appropriate
  weight
• For overweight or at risk (gt85 on BMI curve)
  refer for weight management

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Hyperlipidemia

• Little research in HIV-infected children use
  general pediatric guidelines
• Management
• Dietary changes
• Limit fat intake (lt30 of calories), provide
  adequate calories and nutrients
• Limit concentrated sweets
• Exercise
• Consider medications(little experience in
  pediatric HIV infection)

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Treatment of Nutritional Deficiency and Growth
Failure

• Treat underlying conditions that
• Interfere with nutrient intake or absorption
• Increase nutrient loss
• Provide enough nutrition for catch-up growth
• Consider endocrine evaluation for growth hormone,
  thyroid hormone replacement, other therapies

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Treatment of Nutritional Deficiency and Growth
Failure (2)

• Oral supplementation, dietary management
• Initiate supplements early
• Increase frequency of feedings
• Use concentrated formulas, calorie-dense foods
• Pediatric supplements for ages 1-10
• Isotonic, intact PediaSure, Kindercal, Nutren Jr
• Semielemental (for malabsorption) Peptamen Jr
• Adult supplements for older children
• Vitamin/mineral supplements

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Treatment of Nutritional Deficiency and Growth
Failure (3)

• Lactose intolerance
• Higher prevalence in HIV infection
• Manage with lactose-free diet, lactase
  supplements, soluble fiber, medium chain
  triglycerides, protein hydrolysate formulas
• Consider these measures for children with
  unexplained chronic diarrhea
• Oral and esophageal lesions
• Treat underlying cause (eg, candidiasis)
• Avoid salty, acidic, and spicy foods
• Give soft foods, topical anesthetics (lidocaine
  or diphenhydramine swishes) before meals

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Tube Feeding

• Indication failure of oral dietary management
• Increases fat mass, but may not significantly
  increase lean body mass
• No data to show long-term benefit in nutritional
  status and growth
• Nasogastric tube Initial approach to evaluate
  efficacy of tube feeding but, uncomfortable,
  increases risk of sinusitis, and limits oral
  intake
• Gastrostomy tube for long-term nutritional
  support, medications

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Parenteral Feeding

• Total parenteral feeding (TPN)
• Indication severe nutritional disturbances,
  inability to tolerate enough enteral nutrition to
  maintain appropriate growth
• Continue enteral nutrition while on TPN
• Risk of catheter-associated infection not higher
  in HIV infection

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Appetite Stimulants

• Few pediatric studies
• Megestrol acetate
• Increases fat mass no data on lean body mass
  changes in children
• Insufficient data on other agents

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Recombinant Human Growth Hormone

• In adults, increases body weight and lean body
  mass
• Potential benefit in case of decreased linear
  growth or lean body mass
• Accelerates bone age in proportion to height

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Summary

• Maintaining appropriate nutrition, growth, and
  physical activity enhances efficacy of medical
  treatment and quality of life
• Nutritional intervention should be integrated
  into the care plan of all HIV-infected patients
• Care is most effectively provided by a
  multidisciplinary team (nurses, nutritionists,
  pharmacists, physicians, social workers)
• Therapy must be directed at the entire family