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4.3.9 – Functions of the digestive, metabolic and endocrine systems

Feeding Problems and Poor Growth

There are important feeding and growth issues unique to infants and children:

  • Proper nutrition is one of the easiest ways to facilitate good immune function. 
  • Although antiretroviral therapy has helped reduce poor growth, it is still extremely important to attend to the nutritional needs of infants and children living with HIV.
  • Malnutrition can have a negative effect on immune function and make it more difficult to fight infections.
  • Interventions should be focused on preventing malnutrition as well as careful nutritional assessment and targeted interventions. This can be achieved if there is early detection of either weight loss or a falling off from age- and sex-corrected growth percentiles.
  • The height and weight of children and infants living with HIV should be plotted on appropriate growth curves at regular intervals.


For most babies, breastfeeding is by far the best way to be fed. However, it is possible for breastfeeding to transmit HIV from an HIV-positive mother to her baby. Therefore, the risks and benefits of breastfeeding must be carefully considered by HIV-positive mothers and their supporters. We encourage readers to review up-to-date, easy-to-understand descriptions of advice (e.g., see and about ART for pregnant mothers and infants (e.g., see We note some (but not all) key points about breastfeeding for HIV-positive mothers here.

The WHO 2013 guidelines recommend that HIV-positive mothers in low-income countries:

  • breastfeed exclusively for 6 months if they do not have access to clean water and sanitation and if they are unable to afford formula. Note: In some areas, mothers may qualify for free formula for the first 6 months of their infant's life.
  • continue breastfeeding for 6 months, then introduce complementary foods and wean baby at 12 months
  • administer appropriate ART to the infant
  • breast milk versus formula: The immunological and nutritional benefits of breastmilk far outweigh those gained from formula feeding. Consequently, the World Health Organization recommends exclusive breastfeeding for 6 months for all infants around the globe. However, for HIV-positive mothers, formula feeding is the next best alternative if they have the means to do it safely.

For WHO guidelines:

Feeding Problems and Poor Growth

  • Infants and children living with HIV are at high risk for malnutrition, which can have a negative effect on immunity and make it harder to fight infections.
  • Malnutrition causes a lack of weight gain, poor growth, and even weight loss.

Other important factors that put an infant or child with HIV infection at risk for malnutrition include:

  • Feeding problems
  • Anorexia due to acute or chronic infection and illness
  • Financial resources of the family
  • Stigma

The infant's rehabilitation providers need to address all of these issues. Nutritionists and Speech-Language Pathologists and Occupational Therapists are some of the specialists who can play important roles in this context particularly.

Red Flag: Any change from previously stable growth curves requires immediate medical assessment and intervention with supplemental nutritional strategies.

Red Flag: Any new gastrointestinal symptoms such as mouth sores, vomiting, or diarrhoea require prompt referral for medical assessment.

Any infant or child with "feeding problems" requires a comprehensive feeding history to be taken to help guide the assessment and interventions. Feeding problems may be multi-factorial.

An infant or child's feeding abilities may change with time and with their medical status (e.g. new mouth sores, acute infection, new medications, encephalopathy). Caregivers need to monitor their child's feeding closely and have it reassessed quickly if issues arise.

Before starting an intervention, a feeding assessment is required to identify the specific areas of concern. The assessment is important, as the history or presentation may appear similar in children with very different feeding issues. For example, an infant who is reported to have a "poor suck" and "fall asleep" while feeding may have poor oral motor skills and decreased endurance. However, he or she may also be demonstrating adaptive or protective techniques to limit intake due to an underlying swallowing problem and aspiration or due to discomfort (e.g., reflux or nausea) with oral feeds.

Potential causes of these impairments and rehabilitation interventions are shown in the table below.

Table 4.3.9: Clinical Aspects of Feeding Problems and Poor Growth

Impairments Possible Etiologies Rehabilitation Interventions
Inadequate feeding

Poor oral motor skills

Poor coordination of breathing or swallowing

Tires easily/decreased endurance

  • Position to maximize efficiency of bottle and spoon feeding
  • Modify flow rate of liquids when bottle feeding (flow rate may need to be decreased or increased depending on the child's needs). An Occupational Therapist or Speech-Language Pathologist can assist with determining the correct bottle and flow rate for an infant
  • Spoon liquid, if the baby cannot suck
  • Use higher caloric infant formula as prescribed by a registered dietitian or physician
  • Use infant cereal or maize meal mixed with formula instead of water. It is important to avoid adding formula to cereals that are labelled "add water" as these cereals contain powdered milk. If formula is added, the caloric content can be excessive and dangerous. Ensuring the cereal is labelled "add formula or breastmilk" is very important.
  • Use oral stimulation techniques taught by a therapist to improve suck strength and the coordination of the suck, swallow, and breathe sequence
Self-feeding problems

Poor fine motor and visual-motor skills

Tires easily/ decreased endurance

Developmental delay or regression

  • Use cups with a spout that make it easier to drink
  • Use easy-to-hold finger foods
  • Use a spoon that is not too big or too small
  • Encourage finger feeding
  • Provide opportunities with no stress or expectations on the child for children to experiment and practice self-feeding
  • Improve fine motor/visual motor skills through activities other than feeding
Swallowing problems (including choking with feeds/aspiration)

Mouth/throat sores or pain

Structural abnormalities

Swallowing incoordination

Developmental regression

Encephalopathy or neurologic changes

Anorexia, nausea, vomiting, fatigue, pain

Decreased taste acuity

Abnormal taste

Side-effects of medication

Psychosocial and emotional distress (e.g., separation, anxiety, depression, parent-child interaction, over/underfeeding)

  • Conduct a comprehensive feeding assessment regarding safety of different textures and consistencies and related aspiration risks
  • Avoid foods/textures that the feeding assessment has identified as being a risk for aspiration (e.g., provide thickened liquids if thin liquids are found to cause choking/aspiration)
  • Maintain good dental hygiene. Children should brush their teeth twice a day
  • Avoid foods that are too salty, spicy, or acidic
  • Give soft, smooth, easy-to-chew foods if chewing is difficult or immature
  • Use a straw for drinking, if mouth sores are present
  • Use food that is cold or at room temperature, if mouth sores are present
  • Provide verbal or gestural cues to facilitate swallowing
  • Use a dry swallow after a normal swallow to clear any residue


Medication side-effects

HIV enteropathy

Altered gastric motility

Infections (viral, bacterial, or parasitic)

  • Treat infections
  • Assess gastrointestinal motility and use appropriate medications as required
  • Use dietary interventions as recommended by a registered dietician, often low-fat, low lactose foods
Poor appetite


Side effect of medication

  • Use small, frequent meals
  • Use a higher caloric diet by choosing high-fat dairy products (if tolerated) and adding extra fat foods to table (e.g., butter, margarine, gravy, peanut butter)
  • Give oral nutritional supplements
  • Give nutritional supplements via gastrostomy tube for anorexia