NUTRITIONAL

CONSIDERATIONS FOR HIV INFECTED INFANTS

Nutan Dayaram

Senior Dietitian

Red Cross War Memorial

Children’s Hospital

HIV Infection Symposium May 2011

TALK OUTLINE

1. INTRODUCTION

Nutritional care in HIV

Final Recommendations- WHO 2010 Guidelines

2. NUTRITIONAL REQUIREMENTS FOR HIV + INFANTS

Practical Guidelines and Rationale

3. FEEDING CHOICES

Breast feeding Physiology

Comparison of breast milk vs. formula milk

Breast feeding challenges and problems

4. SUMMARY

1. INTRODUCTION

INTRODUCTION

NUTRITIONAL CARE IN HIV + INFANTS

• Growth Failure, Wasting and loss of active lean

tissue- are associated with increased mortality and

accelerated HIV- AIDS progression

• The use of Highly Active Antiretroviral Therapy

(HAART) has improved the prognosis and life span

of infants infected with HIV and has reduced rates

of wasting1

1ASPEN Clinical Guidelines: Nutrition Support of Children with Human Immunodeficiency Virus Infection, Journal of Enteral and Parenteral Nutrition 2009

WHO 2010 RECOMMENDATIONS

Breastfeeding, which is essential for child survival has posed

an enormous dilemma for mothers living with HIV

WHO states….

“…mothers may safely breastfeed provided that they or their

infants receive ARV drugs during the breastfeeding period.

This has been shown to give infants the best chance to be

protected from HIV transmission in settings where

breastfeeding is the best option.2"

2News Release, WHO announces new approaches to HIV prevention and treatment among children, 20/08/10

2. NUTRITIONAL REQUIREMENTS

OF THE HIV POSITIVE INFANT

NUTRITIONAL REQUIREMENTS

1. Nutrition Assessment of children who are HIV+

should be performed at baseline and in succession

Growth failure is common

No difference in birth weights & gestational age of HIV+

BUT by 3 months of age & up to 5 years children who are

HIV+ have lower weight and height1

Decreased nutrient intake, increased energy requirements,

malabsorption & psychosocial issues may all contribute to

undernutrition

Growth failure is a prognostic indicator of mortality

1ASPEN Clinical Guidelines: Nutrition Support of Children with Human Immunodeficiency Virus Infection, Journal of Enteral and Parenteral Nutrition 2009

2. Oral nutritional supplements may improve weight

and growth in children who are HIV + with growth

failure

When children fail to meet growth standards,

supplementation can restore weight and growth in some

children

Nutritional Supplementation

– NTP programme- Nutritional Therapeutic Programme

– Criteria -to be able to enter Programme

Energy and protein requirements should be estimated in

accordance with growth parameters and not with the disease-

specific state of the infant- WRT HIV

NUTRITIONAL REQUIREMENTS

3. Antiretroviral therapy improves growth in children

who are HIV +

Infants born to HIV+ mothers have a lower weight and

height z-scores from 3 months to 5years

The incidence of wasting has fallen since the

implementation of HAART

NUTRITIONAL REQUIREMENTS

4. Micronutrient supplementation should be

considered in children who are HIV +

Reduced dietary intake of vit E, calcium & vit D is seen in

HIV + children in US

Consumption of a MVT is associated with better bone

mineral density

Vitamin A supplementation has shown to reduce

diarrhoea, URTI and mortality

Zinc supplementation is seen to reduce diarrhoeal illness in

HIV+ infants only

NUTRITIONAL REQUIREMENTS

NUTRITIONAL REQUIREMENTS HIV INFANTS

Fluid requirements• 0-6mnths → 150ml/kg

• 6-12mnth → 100-150ml/kg

Macronutrients equate to normal infant requirements

a. Energy:

0-6mnths- 100 (Normal) -150kcal/kg (catch-up)

6-12mnths- 100 (Normal)-150kcal/kg(Catch-up)

b. Prot: 0-12months →2-4g/kg

c. Fats: 5-6% TE

Micronutrients-Specific for HIV- as mentioned in the text-

– Multivitamin is given to ensure,Vit A, Vit E, calcium & Vit D

is covered

– Zinc added as extra

3. FEEDING CHOICES

WHO RECOMMENDATIONS

Exclusive Breastfeeding for the first 6 months of life

together with antiretroviral treatment/interventions

Formula Feeding -- regardless of AFASS

(Acceptable, Feasible, Affordable, Sustainable, Safe)

Mixed feeding < 6 months

BREAST FEEDING PHYSIOLOGY

MICROSCOPIC STRUCTURE

PHYSIOLOGY OF LACTATION

Involves:

1. Hormones

Prolactin and Oxytocin reflex

2. Sensory stimulation

3. Reflexes (rooting, suckling, swallowing)

4. Suckling action

1

2

3

Prolactin stays in blood 30minutes after feed -makes milk for next feed

PROLACTIN REFLEX

PROLACTIN REFLEX

NIGHT TIME FEEDING

Poor oxytocin reflex leads to baby having

difficulty in getting enough milk.

1

3 2

OXYTOCIN REFLEX

HOW IS THE MILK EJECTED

In the breast oxytocin

makes the muscle cells

around the alveoli

contract making the milk

flow through the duct to

the lactiferous sinuses

Posterior

Pirtuitary

Gland

Milk Ejection Reflex

It is associated with

good feelings

thinking lovingly

being confident

sensations such as touching, seeing baby or hearing baby

cry

Milk ejection can be therefore hindered by :

worrying or being afraid

pain

embarrassment

OXYTOCIN IS THE LOVE HORMONE

SIGNS & SENSATIONS

OF AN ACTIVE OXYTOCIN REFLEX

A mother may notice:

A squeezing or tingling sensation in her breasts just before she

feeds her baby, or during a feed

Milk flowing from her breasts when she thinks of her baby, or

hears him crying

Milk dripping from her other breast when her baby is suckling

Milk flowing from her breasts in fine streams, if her baby comes

off the breast during a feed

Pain from uterine contractions, sometimes with a rush of

blood, during feeds in the first week post partum

Slow, deep sucks and swallowing by the baby, which show

that breast milk is flowing into his mouth.

If one or more of the signs or sensations are present, then a

mother can be sure that her oxytocin reflex is active.

SIGNS & SENSATIONS

OF AN ACTIVE OXYTOCIN REFLEX

BREAST MILK VS. FORMULA MILK

Human milk composition depends on

– stage of lactation,

– duration of feeds,

– gestational age of the infant

BREAST MILK VS. FORMULA MILK

Human milk is complete – made up of every

nutrient necessary for all infants to develop and

grow optimally

Formula is complete in providing all macronutrient

and microntrients necessary for infants

But lack growth factors and immunomodulatory

factors

NUTRIENT

FACTOR BREAST MILK CONTAINS FORMULA CONTAINS

Fats Rich in brain-building omega 3’s

[DHA(docosahexaenoic

acid)/ARA(Arachidonic acid)]

Automatically adjusts to infant's

needs; levels decline as baby gets

older

Rich in cholesterol

Nearly completely absorbed

Contains fat-digesting enzyme,

lipase

No DHA

Doesn't adjust to infant's

needs

No cholesterol

Not completely absorbed

No lipase

Protein Soft, easily-digestible whey

More completely absorbed

Lactoferrin for intestinal health

Lysozyme, an antimicrobial

Rich in brain-and-body- building

protein components

Rich in growth factors

Harder-to-digest casein

Not completely absorbed,

more waste, harder on

kidneys

Does not contain all the

different proteins compared

to BM.

CHO Rich in lactose

Rich in oligosaccharides, which

promote intestinal health

No lactose in some formulas

Deficient in oligosaccharides

Immune

Boosters

Rich in living white blood cells

Rich in immunoglobulins

No live white blood cells-or any

other cells.

Few immunoglobulins and

most are the wrong kind

Vitamins and

Minerals

Better absorbed, especially

iron, zinc, and calcium

Iron is 50 to 75 percent

absorbed.

Contains more selenium (an

antioxidant)

Not absorbed as well

Iron is 5 to 10 percent absorbed

Contains less selenium (an

antioxidant)

Enzymes and

Hormones

Rich in digestive enzymes, such

as lipase and amylase

Rich in many hormones:

thyroid, prolactin, oxytocin, and

more than fifteen others

Varies with mother's diet

Processing kills digestive

enzymes

Processing kills hormones, which

are not human to begin with

Always tastes the same

Adapted from Comparison of human milk and formula www.askdrsears.com/html/2/T021600.asp - 49k-

NUTRIENT

FACTOR BREAST MILK CONTAINS FORMULA CONTAINS

Cost Around $600 (R4,500) a year in extra

food for mother Around $1,200 (R9,000) a year

Up to $2,500 (R18,750) a year

for hypoallergenic formulas

Cost for bottles and other

supplies not included

Lost income when baby is ill

NUTRIENT

FACTOR BREAST MILK CONTAINS FORMULA CONTAINS

EXCLUSIVE FEEDING

CHOICE SHOULD ALWAYS

BE ENCOURAGED

BREASTFEEDING

CHALLENGES & PROBLEMS

WRT TO HIV

• Breast is best!

• BF has everything the baby needs for the first 6 months of life.

• Protective factors against common infections

• Improves cognitive development

• Bond between mother and baby

• It reduces the risk of developing diseases such as GE &

respiratory infections as well as food allergies

• BM can be expressed and stored

BREAST FEEDING COUNSELLING

• It is NB to assess whether mom is BF correctly to

ensure that she continues to BF

• NB to Look at:

– Positioning

– Latching

– Sucking

BREAST FEEDING COUNSELLING

• Breast Conditions

Mothers should be provided counselling to recognise breast

conditions -cracked nipples, mastitis & breast abscesses &

seek treatment immediately

She should express breast-milk frequently from the infected

or sore breast & discard it until the breast is healed & continue

breast-feeding from the uninfected breast

Avoid breast-feeding when the mother has full-blown AIDS

(stage IV)

BREAST FEEDING COUNSELLING

There are many misconceptions/myths about BF:

Some moms don’t have enough milk?

Baby needs extra water?

Expressing is a good way to know how much milk a

mother has?

Moms should not breastfeed if she is sick

Baby with diarrhoea should not breastfeed

Why does breast milk look weak?

…..And many more...

BREAST FEEDING COUNSELLING

Formula Feeding

• It is NB to establish

– What formula is given?

– How formula is mixed?

– Number of formula feeds per day/night?

– Is the mother/father/care-giver employed?

– Do they have electricity and access to running water?

• Counselling needs to be provided based on the

information gathered from above.

FORMULA FEEDING COUNSELLING

• Concerns with Formula Feeding:

Status revealed to the family- Stigma

Product only provided for 6 months

At times not enough stock of milk at clinic

FORMULA FEEDING COUNSELLING

– ONLY @ 6 months

– Strongly discourage initiation of solids (mixed

feeding) < 6 months

– Mom to continue BF / FF depending on choice

• Must reinforce choice

COMPLEMENTARY FEEDING

SUMMARY

NUTRITIONAL REQUIREMENTS

• 1. Nutrition Assessment should be performed at

baseline

• 2. Oral nutritional supplements improve weight &

growth

• 3. ARV’s improves growth

• 4. Micronutrient supplementation should be

considered – given as a MVT

• 5. Macronutrients equate to normal infant

requirements(with catch-up if needed)

Exclusive Breastfeeding for the first 6 months of life together

with ARV treatment/interventions should be promoted

For all HIV POSITIVE infants

– If Breastfeeding

• Protect, Promote & Support

• Discourage mixed feeding in infants < 6 months

• Encourage complimentary feeding at 6 months + BF

– If Formula Feeding

• Ensure correct preparation and hygiene observed

• Discourage mixed feeding in infants < 6 months

• Encourage complimentary feeding at 6 months + FF

FEEDING CHOICES

SUMMARY

For all HIV EXPOSED infants

– If Breastfeeding

• Ensure Infants receiving ARV prophylaxis continue for one

week after BF cessation.

• Protect, Promote & Support

• Discourage mixed feeding in infants < 6 months

• Encourage complimentary feeding at 6 months + BF

– If Formula Feeding

• Ensure correct preparation and hygiene observed

• Discourage mixed feeding in infants < 6 months

• Encourage complimentary feeding at 6 months + FF

FEEDING CHOICES

SUMMARY

THANK YOU