Children with HIV infection may be symmetrically small without meeting the criteria for failure to thrive. That is, the child may be below the 5th percentile in both height and weight and yet maintain a steady growth curve. It is important for clinicians to consider HIV infection in a child who is otherwise asymptomatic but is small for age (i.e., the 7 year old who is the size of a 5 year old; the 5 year old who is the size of a 3 year old).
Growth faltering is defined as failure to gain weight or continuous loss of weight for three consecutive months. Failure to thrive is easy to diagnose if the child's previous growth rate is known, i.e., if the child has been attending a well baby clinic on a regular basis, has been weighed and measured regularly to fill the growth chart. The cause of failure to thrive in a child with HIV infection is not clearly understood. Growth retardation in HIV infected children may be due to lack of adequate feeding or repeated chronic infections, such as, urinary tract infection, diarrhoea and pneumonia.
Children with failure to thrive may also be severely malnourished. The assessment of the severity of malnutrition may be made by examining the child's weight for age. Severe malnutrition includes kwashiorkor, marasmus and marasmic kwashiorkor. In kwashiorkor the child is oedematous and the weight falls between 60 and 80% of the normal weight for age. In marasmus there is no oedema and the weight falls below 60% of the normal weight for age. In marasmic kwashiorkor the child has oedema and the weight falls below 60% of the normal weight for age.
Principles of feeding in infants and children:
The basic goals for good nutrition in infants and children are to ensure satisfactory growth and development. Because of fast growth and development, the nutritional needs of children are high and in children who are HIV positive the needs are even higher because of recurrent infections.
The mother’s breast milk is still the best food for the baby. It offers the greatest protection against infections, malnutrition and premature deaths among children in resource-limited settings. In the context of HIV/AIDS babies should be exclusively breastfed with safe transition to replacement feeding as soon as it is possible. Safe transition means changing feeding rapidly from exclusive breastfeeding to exclusive replacement feeding avoiding mixed feeding. The baby is fed expressed breast milk from a cup in between the breast feeds until he is used to taking milk from the cup. Exclusive replacement feeding should be commenced only when the baby and the mother are comfortable with cup feeding.
Mixed feeding must be avoided at all costs as it is associated with increased risk of HIV transmission to the baby through breast milk.
Formula feeding on the other hand eliminates HIV transmission, but carries an increased risk of childhood mortality related to diarrhoea and other infectious diseases, especially in resource limited settings. Mothers who have chosen this option of feeding need considerable support to ensure adequate supply and proper preparation of baby foods.
Qualitatively, the nutritional needs of HIV positive children are similar to the needs of HIV negative children. Most of these children should feed on three meals per day with two snack in between the meals. However, because of frequent infections these children get, they should take higher amount of energy and body building foods per meal to help maintain lean body weight. All children should receive Vitamin A supplementation where possible.