Growth, Body Composition, and Metabolism

Updated November 2007

I. INTRODUCTION

Recommendation:

Clinicians should perform an annual nutritional assessment as part of routine care for all HIV-infected children (see Table 1).

Click here to view Table 1: Elements of a Nutritional and Dietary Assessment

II. GROWTH ABNORMALITIES IN PERINATALLY HIV-INFECTED CHILDREN AND ADOLESCENTS

Recommendations:

Clinicians should obtain weight and height (or length) measurements every 3 to 4 months until children have reached full adult height.

Clinicians should assess children who are experiencing suboptimal growth for potentially reversible causes of poor growth.

Click here to view Figure 1: Causes of Malnutrition

III. RESTORATION OF GROWTH

A. Energy Intake

Recommendations:

Clinicians should carefully evaluate the dietary intake of children with growth failure or wasting syndrome, and dietary counseling should be provided by a health professional with expertise in pediatric nutrition.

Clinicians should increase total caloric intake as needed for growth, and potential causes of growth failure should be treated when possible.

Caloric intake should be nutritionally balanced: 50%-55% of total calories from carbohydrate; 15%-20% from protein; and 20%-30% from fat (with <10% of total calories as saturated fatty acids).

Click here to view Table 2: Common ARV Side Effects That May Affect Appetite and Nutrition

B. Viral Suppression

Recommendation:

Clinicians should assess the ARV regimen of patients with poor growth and high viral load to ensure optimal efficacy of the ARV regimen.

C. Micronutrients

Recommendations:

Clinicians should prescribe multivitamin and mineral supplements for HIV-infected children with growth problems but should be careful of the potential for overdose.

Clinicians should ensure that any micronutrient supplements that are used conform to the specific RDA for age.

The clinician should obtain a history of use of over-the-counter supplements and herbal supplements.

D. Anabolic Agents

Recommendation:

Anabolic agents should only be prescribed for children in consultation with a pediatric HIV specialist.

IV. NEUROENDOCRINE DISORDERS AND GROWTH

Recommendations:

In patients with unexplained growth failure, clinicians should obtain thyroid function tests.

Clinicians should refer patients to an endocrinologist when growth failure remains unexplained after initial evaluation or when the evaluation suggests an endocrine abnormality.

V. ASSOCIATION OF GROWTH ABNORMALITIES WITH GASTROINTESTINAL INFECTIONS AND MALABSORPTION

Recommendations:

Clinicians should carefully screen HIV-infected children with poor growth for gastrointestinal infection and malabsorption.

When lactose and fat intolerance is suspected, the clinician should consult with a pediatric gastroenterologist for screening and diet adjustment.

VI. LIPODYSTROPHY AND ABNORMALITIES OF LIPID METABOLISM

Recommendation:

Clinicians should screen serum cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein in HIV-infected children initiating HAART, 3 to 6 months after initiation, and approximately every 6 months thereafter. Abnormal results warrant repeat studies performed in the fasting state (see Tables 3 and 4).

VII. MANAGEMENT OF HIV-INFECTED CHILDREN WITH ABNORMAL CHOLESTEROL

Recommendations:

Clinicians should use dietary and behavioral interventions to manage HIV-infected children and adolescents with abnormal cholesterol. Monitoring and dietary management should be in accordance with the guidelines published by the American Academy of Pediatrics (for adolescents, the Adult AIDS Clinical Trials Group Preliminary Guidelines).^20,21

Clinicians should consider the use of pharmacologic interventions for patients with markedly abnormal cholesterol; however, there is the potential for drug-drug interactions, particularly between ARV agents and bile acid sequestering agents.

Clinicians should refer HIV-infected children with borderline or high cholesterol to a pediatric nutritionist or dietitian.

Click here to view Table 3: Classification of Cholesterol Levels in Children Click here to view Table 4: Management of Hypercholesterolemia in HIV-Infected Children and Adolescents

VIII. ABNORMALITIES OF GLUCOSE METABOLISM

Recommendation:

Clinicians should screen for risk factors for diabetes mellitus, including obesity and family history.

IX. BONE DISORDERS

REFERENCES

APPENDIX A

Click here to view Table A-1: Methodologies for Measuring Body Composition

APPENDIX B

Click here to view Table B-1: Percentiles of Upper Arm Circumference and Estimated Upper Arm Muscle Circumference Click here to view Table B-2: Percentiles for Triceps Skinfold Click here to view Table B-3: Body Mass Index Norms (Percentile Values of Body Mass Index*)

APPENDIX C

Click here to view Table C-1: Recommended Energy Intake for Healthy Children

APPENDIX D

Click here to view Table D-1: Selected Nutritional Supplements for Toddlers and Young Children Click here to view Table D-2: Selected Nutritional Supplements for Adolescents

APPENDIX E

Click here to view Table E-1: Step-One Diet Click here to view Table E-2: Step-Two Diet