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.
Breastfeeding
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 http://avert.org/hiv-and-breastfeeding.htm) and about ART for pregnant mothers and infants (e.g., see https://www.avert.org/hiv-transmission-prevention/pregnancy-childbirth-breastfeeding). 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:
The 2016 WHO Consolidated Guidelines on the use of Antiretroviral Drugs for Treating and Preventing HIV Infection are available at http://www.who.int/hiv/pub/arv/arv-2016/en/.
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, speech- language pathologists or speech therapists 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. Children with feeding difficulties should be referred to a speech therapist for a feeding assessment if possible.
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 |
|
| Self-feeding problems | Poor fine motor and visual-motor skills Tires easily/ decreased endurance Developmental delay or regression |
|
| 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) |
|
| Diarrhea | Malabsorption Medication side-effects HIV enteropathy Altered gastric motility Infections (viral, bacterial, or parasitic) |
|
| Poor appetite | Nausea Side effect of medication |
|
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