Growth Monitoring in

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Growth Monitoring in HIV-exposed Infants

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Objectives

• This presentation should help you
• Describe why growth monitoring of HIV exposed
  infants is especially important
• Learn the proper techniques for measuring growth
  (conducting weight, height, and head
  circumference) in children
• Learn the proper techniques for plotting growth
  parameters on growth charts
• Learn how to interpret growth charts
• Define failure-to-thrive (FTT) and growth failure
  (GF)
• Recognize when to refer the infant with FTT/GF
  for evaluation

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Growth a Pediatric Vital Sign

• Growth and development are the work of the
  child
• Growth is an optimal nutritional indicator in
  children
• Clinical manifestations of growth failure
• Slow weight gain or weight loss is first to occur
• Prolonged period, linear growth (length) is
  affected
• Brain growth as measured by head circumference
  is last to be affected

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Growth Monitoring is a Critical Component of
Pediatric HIV Care

• Abnormalities in growth are common in HIV-exposed
  infants
• Growth failure early in life can be the first
  manifestation of HIV-infection
• Can indicate rapid disease progression (seen in
  HIV-exposed infants before laboratory diagnosis
  of infection can be made)
• Can occur secondary to opportunistic infections,
  complications of HIV disease, other infections
• Can be due to psychosocial issues food scarcity,
  caregiver illness, change in family dynamics,
  depression

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What are the Components of Growth Monitoring?
Step 1 Obtaining Accurate Measurements

• Begins with measuring and charting weight, length
  and head circumference
• Weight if only one measurement can be done, this
  is the most crucial
• Head circumference this is the second most
  crucial in children under 2 years of age as it
  indicates brain growth
• Height/length

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Weighing Scales

• To enhance accuracy of measurements
• Use same scale at each visit
• Scale should be zeroed daily and calibrated
  weekly
• Infant scales should be used for children 20kg

Infant balance scale
Simple hanging scale
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Weighing Infants

• Remove all clothing
• You can weigh infant wearing a dry diaper
• Weigh infants supine
• Record weight to the nearest 0.1 kg

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Weighing Older Children

• Remove all clothing
• Weigh older infants sitting with dry diaper
• Record weight to the nearest 0.1 kg

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Measuring Head Circumference

• Use a non stretchable plasticized tape
• Measure head circumference to obtain greatest
  volume
• Record measurement to the nearest 0.5cm
• Measure head circumference up till 24 months of
  age

Place tape at midforehead and extend
circumferentially to include most prominent
portion of occiput
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Measuring Infants

• Measure length of children 0-2 years supine
• Use 2 people
• Straighten knees and keep ankles in neutral
• Record measurement to the nearest 0.5cm or ½ inch

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Length Board
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What are the Components of Growth Monitoring
Step 2 Using Growth Charts

• Rates of growth are crucial assessments for
  children
• A rate of growth measures the change in a babys
  growth over a specified period of time. Another
  way of saying this is, How fast is the baby
  growing?
• A growth chart allows us to see if that change is
  what it should be compared to normal rates of
  growth.
• It is not enough to simply gain weight or height
  but the child should be growing at an appropriate
  rate. This can only be recognized by connecting
  the dots on growth charts (creating a growth
  curve) and comparing the babys curve to the
  pre-printed curves.
• Height and weight should be plotted for all
  children, head circumference should be monitored
  for all children under 2 years of age.

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What are the pre-printed curves?

• Growth data collected from large numbers of
  children in a particular population
• Normative growth rates (curves) created normative
  data on weight, height and head circumference by
  age and sex

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Why Use Growth Curves?

• Easy and systematic way to follow CHANGES IN
  GROWTH OVER TIME for an individual child
• Height, weight and head circumference should be
  plotted at regular intervals
• Monthly till 6 months of age
• Quarterly till 18 months of age

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How to Use and Interpret a Growth Curve

• Measure and weigh child using same methodology at
  each visit
• Using age and sex appropriate charts, plot
  measurement on the vertical axis against age on
  the horizontal axis.
• Connect the dots and compare growth point with
  previous points
• Assess growth percentile and look at the rate
  (speed of growth) over time

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WHO Growth Charts
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Johns growth curve
No weight gain
Birth- 2.5 kg 1 mo- 3.4 kg 2 mos- 3.4 kg
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Marys growth curve

• Birth 4.2 kg
• 1 mo 4.6 kg
• 2 mos 5.0 kg
• 3 mos 5.2 kg
• 4 mos 5.6 kg

Weight Gain But Growth Failure
Despite weight gain, declined from 97-15
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Defining Failure to Thrive(FTT)/Growth Failure
(GF)

• There are several definitions
• Serial weight or height measurements that
  downwardly cross 2 major percentile lines on the
  growth chart over time
• For a child already to follow along its own upward curve

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Assessment of Growth Failure in the HIV-exposed
infants

• In resource-limited settings, determining the
  cause of growth failure can be challenging as
  there are many factors that can be acting
  simultaneously.
• It is crucial to determine if HIV-infection is
  the cause of growth failure in any HIV-exposed
  infant

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How do You Assess the infant with FTT or GF?

• Nutrition history to differentiate the child with
  inadequate intake from the one experiencing
  excessive losses
• Physical examination
• Laboratory evaluation- check HIV status
• Assessment and plan

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Nutritional History

• If the infant is failing to thrive, the
  nutritional history should be more extensive than
  the one taken at a routine clinical visit, and
  should include
• Symptoms that might impair nutritional status
  (pain, oral lesions, GI losses, acute illness)
• Breastfeeding history is there a problem with
  latching, is she producing enough milk, did she
  recently wean the infant, what is she feeding the
  infant now?
• If feeding formula how does she prepare it, has
  access to/availability of formula changed
  recently? Has there been a change in family
  finances?
• Has mother noticed that something is wrong? What
  does she think is the cause?

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Physical Examination

• Evidence of impaired oral intake, oral ulcers and
  lesions
• Look for signs of vitamin or micronutrient
  deficiency
• Skin changes suggestive of Kwashiorkor
• Localizing signs of infection
• Evidence of HIV infection-hepatosplenomegaly,
  dermatitis, and thrush

Marasmus
Kwashiorkor
Photos from WHO Child Growth Assessment Training
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Laboratory Assessment

• Poor growth in an HIVexposed infant is
  HIV-infection until proven otherwise.
• Send DNA PCR
• Further work up and laboratory tests as
  determined by
• Symptoms/signs
• Local guidelines

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Assessment and Plan

• Determine etiology of failure-to-thrive
• HIV disease
• Inadequate intake
• Excessive losses
• Develop treatment plan as determined by available
  resources and local guidelines
• Treatment of acute illness
• Provision of food, referral to local resources
• Nutrition counseling
• DETERMINATION OF HIV STATUS

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Which Infants Should be Referred for Evaluation?

• All HIV-exposed infants with
• Growth failure or Failure-to-Thrive
• should have DNA PCR done and be referred for
  further evaluation
• NOTE Food security must be assessed for this
  baby, but this assessment should not delay
  referral

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Summary

• Growth monitoring is a cheap effective way to
  identify children who require extra care
• Parents must be educated on the importance of
  growth, and the need to bring their babies for
  regular assessment
• At each visit weigh, measure and examine child
• Use growth curves to monitor growth patterns
• Growth faltering or failure-to-thrive requires
  prompt work-up and evaluation of HIV status
• Nutritional support must be directed at the
  entire family

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Cases
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Case 1 Doreen

• Doreen is a 3 month old HIV-exposed infant who is
  being exclusively breast fed.
• She is currently on cotrimoxazole prophylactic
  therapy and has been followed in the under-five
  clinic since birth
• Her mother is concerned she is not getting enough
  breast milk and wants to supplement with infant
  formula and porridge
• She was 2.5kg at birth, 3.4 kg at 6 weeks and
  currently weighs 4.4kg

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Case 1Doreen

• Plot Doreens growth chart
• What do you want to know?
• What will you tell the mother?

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Doreens Growth Curve
Weight Birth-2.5kg 6 wks-3.4kg 3mos-4.5kg
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Case 1 Doreen

• You explain to the mother that her daughter is
  getting enough from the breast milk
• She was small at birth and is growing along her
  curve
• Encourage her to continue exclusive breastfeeding
  till 6 months of age
• Explain the risk of transmission of HIV when
  mixed feeding is practiced
• Write a prescription refill for cotrimoxazole
• Schedule follow-up in 1 month

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Case 2 Emily

• Emily is a 4 month-old enrolled at your clinic
  since birth
• When she was two months old, her virologic HIV
  test was negative
• She is in clinic for routine follow up
• Birth Parameters
• weight 3 kg length 48 cm HC 33 cm
• Current Parameters
• weight 5 kg length 57 cm HC 40 cm

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Case 2 Emily

• Mother reports that the baby is doing well. She
  has had no infections or problems.
• Mother is exclusively breastfeeding but baby does
  not feed more than a few minutes on each breast
  before falling asleep.
• She is taking cotrimoxazole as prescribed and
  adherence is good.
• Her weight has been as follows 3.2kg at birth,
  4.2kg (1 mo), 5.2kg (2 mo), 5.4 kg (3 mo), and 5
  kg (4 mo)
• The rest of her examination is normal

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Case 2 Emily

• Plot Emilys growth chart
• How would you describe Emilys growth?
• How would you assess her?
• How does this affect her management?
• What would you recommend at this point?

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Emilys Growth Curve
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Case 2 Emily

• Emily has failure-to-thrive. She has crossed two
  percentiles for weight.
• Conduct a complete nutritional assessment,
  getting more details about feeding patterns,
  latching,etc.
• Ask about other illnesses suggestive of HIV
  infection
• Full evaluation should be done to determine
  etiology, including repeat DNA PCR.