NUTRITIONAL CONSIDERATIONS FOR HIV INFECTED INFANTS Nutan Dayaram Senior Dietitian Red Cross War Memorial Children’s Hospital HIV Infection Symposium May 2011
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