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SOUTHTOSOUTH

Nutritional Supportfrom Birth through AdolescenceFACILITATOR’S MANUAL

FXB BOOKS_1.indd 16 21/9/10 12:21:10

HIV Care & Treatment Training Series Module 5•1

THE SOUTH TO SOUTH PARTNERSHIP FOR COMPREHENSIVE FAMILY HIV CARE AND TREATMENT PROGRAM (S2S) South Africa has the largest HIV burden of any country in the world, with an estimated 5.7 million people living with the virus. Women and children remain at the centre of the pandemic in terms of transmission, vulnerability and potential for impact. To continue to build on the existing successes of South Africa’s antiretroviral (ARV) program, the capacity for HIV disease management must be enhanced. It is essential that HIV disease management transition from an individual case management to a family-centred and chronic-care approach targeting and prioritising pregnant women and children. Enrolling pregnant women and children into HIV care and treatment early and regularly can prevent new HIV infections and reduce morbidity and mortality, effectively sustaining the quality of life of mothers, their children, and their families. The scale up of effective prevention of mother-to-child transmission (PMTCT) and paediatric ARV care and treatment programs are crucial in the fight against HIV but are challenged by many factors including perceived complexity of treating pregnant women and children, inadequate paediatric and PMTCT knowledge and clinical skills, lack of psychosocial and adherence support, delays in integrating PMTCT services with antenatal and child health management systems, and gaps in referral systems. The South to South Partnership for Comprehensive Family HIV Care and Treatment Program (S2S), a collaboration between the Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, and the International Centre for AIDS Care and Treatment Programs (ICAP), Mailman School of Public Health, Columbia University, New York, aims to address these gaps in support of quality HIV care and treatment services. This is accomplished through the provision of comprehensive technical, programmatic, capacity building and systems support for healthcare workers at public health care facilities throughout South Africa by integrating and strengthening PMTCT, paediatric HIV and adherence and psychosocial (APS) programs. S2S is funded by the United States Agency for International Development (USAID). ACKNOWLEDGEMENTS The “HIV Care and Treatment Training Series”, serves as a comprehensive collection of training material for members of the multidisciplinary team caring for women, infants and children living with HIV and their families in South Africa. Module 5: Nutritional Support from Birth through Adolescence was developed by the South to South (S2S) team, in collaboration with and with support from the International Center for AIDS Care and Treatment Programs (ICAP) of Columbia University Mailman School of Public Health. S2S would like to thank the François-Xavier Bagnoud (FXB) Center, School of Nursing, University of Medicine and Dentistry of New Jersey, for coordinating development of the module. Members of the FXB Center consultancy team who provided technical expertise in the development of this module included: Pamela Rothpletz-Puglia, Virginia

Module 5•2 HIV Care & Treatment Training Series

Allread, Mary Jo Hoyt, Deanne Samuels, Carli Rogosin, Jennifer Kasper, Deborah Hunte and Anne Reilly. Development of this module was supported by funding from USAID and US President's Emergency Plan for AIDS Relief (PEPFAR). DISCLAIMER The content expressed herein does not necessarily reflect the views of the USAID. Although every effort was made to ensure that all information in this document is accurate and up-to-date, the authors accept no liability for the consequences of inaccurate or misleading data due to errors in writing or printing/duplication. Every effort has been made to ensure that drug doses are presented accurately, but readers are advised that these should only be followed in conjunction with the drug manufacturer's published literature.


CCOONNTTEENNTTSS

Foreword for Facilitators .........................................................................................................7 Using this Facilitator Manual ..............................................................................................7 Course schedule ....................................................................................................................7 Managing time .......................................................................................................................9 Amending or replacing exercises ........................................................................................9 Anonymous question bowl, basket or envelope ............................................................11

Session 5.1 Growth Monitoring ............................................................................................12 Growth monitoring for HIV-exposed and HIV-infected children .............................13 Visual assessment................................................................................................................15 Measuring weight ...............................................................................................................17 Measuring length and height .............................................................................................19 Measuring head circumference .........................................................................................21 Measuring mid-upper arm circumference .......................................................................22 Growth charts......................................................................................................................22 Interpreting growth charts.................................................................................................25 Growth faltering..................................................................................................................27

Session 5.2 Nutrition Assessment from Birth through Adolescence in the Context of HIV............................................................................................................................................31

Introduction to nutrition assessment ...............................................................................32 Steps in the nutrition assessment......................................................................................33 Clinical signs of malnutrition ............................................................................................38

Session 5.3 Nutrition Requirements and Feeding Recommendations for HIV-Exposed and HIV-Infected Children....................................................................................................43

Growth from infancy through adolescence ....................................................................44 The cycle of nutrition and HIV ........................................................................................45 Nutrition and ARV therapy...............................................................................................46 Growth during infancy.......................................................................................................47 Child and adolescent growth.............................................................................................48 The 24-hour recall...............................................................................................................49

Session 5.4 Prevention of Food- and Water-borne Illness................................................52 Preventing food-borne illness ...........................................................................................52 Preventing water-borne illness ..........................................................................................54

Session 5.5 Nutrition-Related Side Effects of ARV Therapy ...........................................56 Side effects of ARVs...........................................................................................................57 Traditional healers and remedies ......................................................................................59

Session 5.6 Management of Nutrition-Related Symptoms ...............................................60 Nutrition management of HIV and AIDS-related symptoms .....................................61 Diarrhoea..............................................................................................................................62 Poor appetite........................................................................................................................64 Nausea and vomiting..........................................................................................................65 Sore mouth or throat pain when eating...........................................................................66 Anaemia................................................................................................................................67

Session 5.7 Nutrition Counselling and Referrals ................................................................69 Nutrition counselling..........................................................................................................69 Nutrition-related referral....................................................................................................72

Session 5.8 Care of Children Who are Underweight or Wasted ......................................77 Managing growth problems...............................................................................................78 Care and support for undernourished children with HIV infection ...........................79

Appendix 1 Body Mass Index (Children Age 0-5 Years) and Z-Scores..........................83


Body mass index (BMI)......................................................................................................83 Calculating BMI...................................................................................................................83 Trends in BMI-for-age .......................................................................................................84 Z-Scores ...............................................................................................................................84

Appendix 2 Road to Health Booklet (Boys)........................................................................89 Appendix 3 Road to Health booklet (Girls) ........................................................................91 Appendix 4 Head Circumference Growth Charts (Boys Age 0-5 Years) .......................93 Appendix 5 Head Circumference Growth Charts (Girls age 0-5 years) ........................94 Appendix 6 Communication Skills Checklist ......................................................................95 Appendix 7 Example Nutritional Risk Score Card ............................................................96 Resources for Further Information ......................................................................................97 References.................................................................................................................................98


MODULE 5 Nutritional Support from Birth through Adolescence

DURATION 8 hours 30 minutes

LEARNING OBJECTIVES By the end of this module, participants will be able to: Describe the rationale for growth monitoring of children. Review the measurement of weight, length/height, head

circumference and BMI of children. Plot anthropometric measurements and interpret growth charts. Describe methods for assessing nutritional status. Discuss clinical signs associated with undernutrition. Describe nutrition requirements from infancy through adolescence. Describe how to evaluate a 24-hour recall for food group adequacy. Describe the prevention of food- and water-borne illness. Describe common nutrition-related side effects of ARVs. Discuss traditional healers and traditional remedies in the context

of HIV. Describe the management of common nutrition-related symptoms. Discuss care and support of underweight/wasted and severely

underweight/severely wasted children. Practise conducting nutrition counselling. Develop a preliminary referral network for nutrition-related

services.

CONTENT 5.1 Growth Monitoring (1 hour 45 minutes) 5.2 Nutrition Assessment from Birth through Adolescence in the

Context of HIV (1 hour 15 minutes) 5.3 Nutrition Requirements and Feeding Recommendations for HIV-

exposed and -infected Children (60 minutes) 5.4 Prevention of Food- and Water-borne Illness (30 minutes) 5.5 Nutrition-related Side Effects of ARV Therapy (30 minutes) 5.6 Management of Nutrition-related Symptoms (60 minutes) 5.7 Nutrition Counselling and Referrals (90 minutes) 5.8 Care of Children who are Underweight or Wasted (60 minutes)

METHODOLOGY Facilitated presentation, group discussion, case studies in small and large groups, role play


MATERIALS AND RESOURCES Case Study Supplement Markers, flip chart, tape

WORK FOR THE FACILITATOR TO DO IN ADVANCE Review the module carefully, both technical content and the

training exercise. Note that the target audience includes nurses, counsellors, nutritionists and other clinic staff, therefore the technical level of the training should be appropriate for this group. Give yourself plenty of time, at least two weeks, to learn the material so that you can present and facilitate discussions effectively.


FOREWORD FOR FACILITATORS

This training, which includes both classroom and clinical experiences, is designed to be implemented in — or at least near — a clinical setting. The ideal setting is a classroom or meeting space adjacent to a clinic. This training is designed for a multi-disciplinary group of healthcare workers, probably from a single clinic but maybe from a couple of clinics, who will be trained in a clinic setting. The ideal number of participants is 12-20. This module, Module 5: Nutritional Support from Birth through Adolescence includes technical content, advice on how to plan and teach the technical content, and exercises as well as answers to the exercises. The companion Participant Manual includes the key technical content.

USING THIS FACILITATOR MANUAL

Keep the Facilitator Manual with you each day for use as a reference, but avoid reading directly from it during sessions. This module is organised into seven sessions. Each session starts with an outline of the suggested steps for teaching the session in the shaded box entitled “Session overview for facilitators”. The session technical content follows and includes boxes entitled “Facilitator instructions” to offer advice on how to facilitate discussion and teach the content. To support discussion of the knowledge and skills needed for implementation of paediatric care, it is suggested that this module be taught in a manner that is highly interactive, rather than the tradition lecture style. The facilitator should engage all participants and encourage them to contribute to the group.

COURSE SCHEDULE

This course should take approximately nine hours to teach in the classroom. Additional time is needed for learning, practising and demonstrating the assessments covered in this module. The amount of time needed for this clinical component will depend upon the baseline knowledge and experience of participants, as well as the availability of mentors who can supervise clinical practise. Because of the intensity of the content and need for breaks including lunch, it is recommended that the course is taught over at least two days. The course could be organised in any of the following ways, depending on participant availability: Over one and a half or two consecutive days as described in the course schedule on

the next page. Every afternoon for three or four afternoons. The three or four afternoons could be

consecutive or over the course of a couple of weeks. This configuration would give


participants an opportunity to spend the morning in clinic where they have opportunity for clinical practice.

On two consecutive or alternate Saturdays. A course schedule appears below, but the facilitator should feel free to re-structure the course to best fit participants’ schedules. Course schedule Day 1

Time Content

8.00 Welcome and introductions; ground rules 8.30 5.1 Growth Monitoring (1 hour 45 minutes) 10.15 Morning break 10.30 5.2 Nutrition Assessment from Birth through Adolescence in the Context

of HIV (1 hour 15 minutes) 11.45 5.3 Nutrition Requirements and Feeding Recommendations for HIV-

exposed and –infected Children (60 minutes) 12.45 Lunch 13.45 5.4 Prevention of Food- and Water-borne Illness (30 minutes) 14.15 5.5 Nutrition-related Side Effects of ARV Therapy (30 minutes) 14.45 5.6 Management of Nutrition-related Symptoms (60 minutes)

Exercise 5 (40 minutes) 15.30 Afternoon break 15.45 5.6 Management of Nutrition-related Symptoms continued 16.00 Question and Answer Day 2

Time Content

8.00 Summary of key points from previous day and questions 8.30 5.7 Nutrition Counselling and Referrals (90 minutes) 10.00 Morning break 10.15 5.8 Care of Children who are Underweight or Wasted (60 minutes) 11.15 Module Summary (10 minutes) 11.25 Question and Answer


MANAGING TIME

Estimated times are included in this manual for each lecture and exercise. All of the curriculum content is important; however, the facilitator should acknowledge the particular needs, knowledge and experience level of the group and make adjustments accordingly. This will allow more time to be spent on sessions that are less familiar to participants.

AMENDING OR REPLACING EXERCISES

The facilitator should feel free to change, replace or drop training exercises that appear in this module. There are many reasons a facilitator may wish to adapt an exercise. For example, if the session has been simplified to suit participant learning needs, exercises may also have to be simplified. When substituting an exercise in the module with one that is more relevant to participant learning needs, the facilitator should ensure that all the points to be included in the debriefing are included as part of the new exercise. For example, if the facilitator wants to ensure that key issues about developmental assessment are emphasized in a case study, he or she should design cases that include assessment of children at different ages and with different diagnoses. When adapting, amending or replacing an exercise, the facilitator should ask these questions: 1. Is the new exercise consistent with the content in the session? 2. Does the new exercise fit in the amount of time available? 3. Does the new exercise contribute to the variety of exercises in the module as a

whole? 4. Are the activities in the new exercise clearly described, step-by-step? 5. Does the new exercise give participants an opportunity to synthesise and apply newly

learned technical content? 6. What advantages does the new exercise have over the original exercise? 7. What materials will be needed? FACILITATOR PREPARATION CHECKLIST Daily preparation Each day, arrive with enough time to set up the materials and equipment, and arrange the furniture and audiovisual equipment in a way that fosters learning and teamwork. Session content and additional materials In advance of the training, familiarise yourself with the content of the sessions you will be teaching, including the exercises. National guidelines and policies should be available for reference. Although you, as the facilitator, may not be able to answer every question, you should try to master the curriculum content and related support materials.


Room set-up An informal arrangement is more comfortable than a classroom-type arrangement, which creates a formal “lecture” atmosphere. Set up the room so participants can see each other and facilitators have space to walk around. Arrange the seating so that during lectures, participants will be able to see the flipcharts and see the slides and/or overheads on a screen. Ensure that the physical environment is comfortable and well-lit. Create a psychological environment where participants feel accepted, respected, and supported; this will facilitate participation. Consultation with co-facilitators If you are teaching with another facilitator, consult with your co-facilitator prior to the training to coordinate your presentations and other training activities. Facilitators should be willing and available to assist with their colleague’s sessions, particularly with the small group exercises but also taking notes on flipchart. Goals and objectives To focus the training, display on a white or blackboard or on a flipchart, the module objectives and the training ground rules. Course equipment, materials, and teaching aids Have the following materials available if possible: Overheads or PowerPoint slides for the module Overhead or LCD projector and extra extension cord/lead (where available) Flipchart or whiteboard and markers or blackboard and chalk Pencil or pen and writing paper for each participant A clock or watch to keep track of time Anonymous Question Bowl (or Basket or Envelope) — see below — where

participants can submit questions they do not want to ask in front of the group Relevant documents and other materials, such as national guidelines

Be sure that all educational equipment (overhead projector, screen, and/or computer) are in good working order and that materials (flipcharts, white or blackboard, markers, pens, pencils, paper or note cards, tape) are available. Additional materials may be necessary for some exercises, check the Facilitator Manual. Strategies for daily review of key points If the training spans more than one day, start successive days with a short summary of key points from the previous day’s training. The summary of key points form the previous day can be accomplished in any number of ways: Write the key points on the board or flipchart in the morning before participants

arrive. Present key points using a lecture and question-answer format. Use a large group discussion format, asking the group, for example: “What were

the most important points from yesterday’s presentation?” The facilitator should then add any additional key points that the group may have missed.

Divide participants into small groups (or pairs) and give the groups about five


minutes to write down the three most important points from the previous day’s presentations. After the groups re-convene, ask the groups to summarise the points that they identified.

Once the key points have been summarised, ask participants if they have questions about the material covered the previous day.

ANONYMOUS QUESTION BOWL, BASKET OR ENVELOPE

Some questions are difficult to ask in a group. One way to encourage participants to ask questions is to set up a question bowl, basket or envelope along with paper and a pen or pencil, somewhere near the door or on the way to the most used room exit. Tell participants about the bowl (or basket or envelope), and show them where it is. Invite them to submit questions or feedback about the course or course content at any time by writing their question on a piece of paper and placing the paper in the bowl or envelope. Explain that the questions may include concerns about themselves, their families, co-workers or clients. Participants may also use the anonymous question bowl to provide feedback about the course. Check the bowl daily, perhaps after lunch or before finishing for the day. Read the questions aloud to the group and respond if you know the answer. If you do not know the answer and the question is technical, look it up and get back to participants. If a question concerns a topic that is to be covered later in the course, tell the participants that you will wait to address the question until that time (and record the question someplace, like a “Parking Lot” so that you will not forget). If the question is controversial, consider posing the question to the group for discussion. Introduce the Anonymous Question Bowl (Basket or Envelope) in the first half hour of the training, probably just after introductions. ENDNOTE TO FACILITATOR FOREWORD As a course facilitator, you are a catalyst of learning, not merely an instructor. Encourage participants to identify what they want to get out of the course (their personal aims and objectives for the course) — perhaps they can do this as part of an introductory exercise. As a facilitator, you will help them accomplish those aims and objectives.

Remember — all members of the group respect and learn from each other's unique skills, perspectives and life experiences.


SESSION 5.1 GROWTH MONITORING

SESSION DURATION 1 hour 45 minutes

SESSION LEARNING OBJECTIVES Describe the rationale for growth monitoring of children. Review the measurement of weight, length/height, head

circumference and BMI of children. Plot anthropometric measurements and interpret growth charts.

SESSION OVERVIEW FOR FACILITATORS

Step 1: Review the learning objectives for the entire module, pointing out those for this session.

Step 2: Assess learning needs by asking participants about previous attendance on “growth monitoring” training courses, such as Module 1 (of this training series). Ask how many participants monitor child growth as part of their job. Adjust training time and content based on participant experience.

Step 3: Explain why a nutrition module would start off with content on growth monitoring by noting that growth monitoring is one way to screen for need for nutritional support.

Step 4: Introduce the topic of growth monitoring, its importance and the key measurements used to monitor growth.

Step 5: Discuss the visual assessment, using this as an opportunity to discuss kwashiorkor and marasmus.

Step 6: Summarise how to measure weight, length/height and head circumference.

Step 7: Discuss how to chart anthropometric measurements with a focus on the Road to Health booklet.

Step 8: Discuss how to interpret growth charts and growth faltering. Step 9: Facilitate Exercise 1: Growth Faltering Plotting Exercise and (if

desired) Exercise 2: Plotting Exercise, case studies (Note: this is a separate document).

Key Points: The key points for this session are:

The objective of growth monitoring and promotion efforts is to support parents to ensure their child’s growth rate is adequate.

Recognising when children do not grow at appropriate rates is critical to understanding the health of children.


Growth monitoring is important for all children, not just those living with HIV.

Accurate measurement and plotting is critical to identifying and addressing slowed growth in all children, including children living with HIV.

Note: Initiate each section through facilitated discussion, using the key

questions in the “Facilitator Instructions” boxes (below.) When you present the content, you need only cover the material not already mentioned during the discussion. Any topics that come up before they are timetabled (as per the module outline) can be “parked” on a flip chart as a reminder for later discussion when that topic is covered.

GROWTH MONITORING FOR HIV-EXPOSED AND HIV-INFECTED CHILDREN

FACILITATOR INSTRUCTIONS

Start the discussion by asking: Why does this module — a module on nutritional support — start with a discussion

of growth monitoring? To encourage discussion, ask participants familiar with growth monitoring and

the Road to Health booklet to: Briefly describe the reasons why growth monitoring is important especially for HIV-

exposed and -infected children. How is growth monitored? What is your experience with growth monitoring? What are the barriers to

performing growth monitoring? How can these be addressed? Now that the Road to Health booklet has been updated, how many people are

now measuring length/height as well as weight? Who is familiar with measuring head circumference?

NUTRITION AND GROWTH MONITORING An adequate rate of growth is the hallmark of good nutritional status in children; growth problems may be indicative of acute and/or chronic health problems. Given the serious nature of inadequate weight gain, particularly among children with HIV, caregivers should be encouraged to request health care promptly when they think their child is losing weight or not gaining weight sufficiently, even if it is not yet time for their child’s routine growth monitoring visit. Growth monitoring provides an opportunity for the healthcare worker to intervene to prevent serious growth problems. Nutritional interventions should be an integral part of the care of an HIV-exposed or infected child. Improved diet may enhance antiretroviral treatment (ART) acceptability, adherence and effectiveness. The provision of nutritional intervention and support is labour intensive, so it makes sense to provide this level of education, counselling and referral to those for whom it is needed. The way to screen for need is to review growth


monitoring information for each and every infant and child at each and every health facility visit. Children whose growth is faltering are then targeted for nutritional assessment and appropriate interventions based on the growth monitoring information. Each of these concepts (growth faltering, nutritional assessment and nutrition interventions) is discussed in the Sessions that follow. Growth monitoring is a part of each clinic visit for every child. Growth monitoring, which includes measures of height, weight and head circumference, is critical for the prevention and early identification of growth faltering. Since growth problems often precede a medical diagnosis, growth issues may be indicative of medical problems or HIV disease progression. GROWTH AND GROWTH MONITORING Growth is a term used to describe the process of growing — the increase of size and development from a simple to a more complex form. Growth is not simply a uniform process of becoming taller or larger; it involves changes in shape and body composition. For example, the majority of brain cells are present by six months of age. By the time the infant is one year of age, the brain has achieved nearly two-thirds of its final size, and by two years, four-fifths of its final size. The skeleton, by contrast, continues to be formed until 15-20 years of age — making it vulnerable to factors adversely affecting growth throughout childhood and adolescence. Undernutrition in the first two years of life can result in irreversible damage to a child. This time in a child’s life should be considered the “window of opportunity” to establish good nutrition and avoid irreversible damage. Growth monitoring is critical for the evaluation of children’s health and nutritional status and is the single most important preventive procedure that healthcare workers can conduct for children, and especially for children living with HIV. It can be carried out regularly at minimal cost and the benefits of monitoring growth are well worth the time and effort. The interpretation of growth is based on a number of indicators, described in Table 5.1. Table 5.1: Description of growth indicators Growth Indicator Description

Weight-for-age (W/A) Universally used and is the easiest indicator to use when the child’s age is known.

Reflects body weight relative to the child’s age on a given day

W/A screens for underweight for age. Length/height-for-age Reflects attained growth in height.

Screens for stunting, which implies long term inadequate nutrients and calories.

Indicates long-term or chronic nutritional problems. Weight-for-length/height Indicator of weight relative to height.

Reliable growth indicator even when age is not known and is an indicator of wasting and overweight/obesity

Wasting is usually caused by a recent illness or food

Growth faltering (failure to thrive) involves failure to meet expected potential in growth and other aspects of well-being.


shortage, although chronic undernutrition or illness can also cause this condition.

Head circumference (HC)

Defined as length around the largest part of the head Provides clues about brain development

Mid-upper arm circumference (MUAC)

For a child aged 6-60 months, a length around the middle of the upper arm that is less than 115 mm is a reliable indication of severe acute malnutrition.

Body mass index (BMI) and BMI-for-age

Useful to screen for overweight and obesity. BMI-for-age chart and weight-for-length/height chart

tend to show very similar results. Additional information on BMI is in Appendix 1.

There are other anthropometric measures including skin fold measurements and Waterlow criteria, which are beyond the scope of this module. These measures provide alternative means of assessing growth based on standard criteria. KEY STEPS IN GROWTH MONITORING The key steps in growth monitoring are as follows: Record/confirm the child’s name, sex and date of birth (record new demographic

information in the child’s Road to Health booklet). Determine the child’s age as of today’s date. Make a visual assessment of the child (e.g. does the child appear thin, fat, active,

lethargic, anaemic) and observe for signs of marasmus or kwashiorkor. (See next section.)

Weigh the child. (Discussed later in this Session.) Measure the child’s length or height. (Discussed later in this Session.) Measure the child’s HC. (Discussed later in this Session.) Measure the child’s MUAC. (Discussed later in this Session.) Calculate the child’s BMI using the BMI table in the Road to Health booklet. Record results on the Road to Health booklet.

VISUAL ASSESSMENT


To encourage participation, ask: Is it possible to know if a child is malnourished even before you take and plot their

weight or length/height? [Answer: yes, based on a visual assessment you may see that the child is anaemic, has marasmus or kwashiorkor.]

There are four conditions that indicate a child is undernourished and will require a referral even before you’ve done the growth monitoring. What are these conditions?

Anthropometry is the study concerned with the measurements of the proportions, size and weight of the human body.


When a child is undressed for weighing, make a visual assessment of the child (e.g. does the child appear thin, fat, active, lethargic, etc.). Is the child bright eyed and attentive? Or does she or he appear ill, with dull hair and eyes, and is lethargic? Take note of any clinical signs of severe undernutrition. Does the child have signs of anaemia — skin colour seems unusually pale, particularly in the nails, lips and inside the eyelid. It is important to recognise signs of marasmus and kwashiorkor since they require urgent specialised care that may include special feeding regimens, careful monitoring, antibiotics, etc. Marasmus and kwashiorkor are syndromes that are usually evident on visual assessment. In cases where oedema is present, the oedema may obscure weight loss, making it important to assess both the child’s appearance and the growth measurements to ensure an accurate diagnosis. Regardless of their weight, children with these syndromes should be referred for urgent care. MARASMUS (NON-OEDEMATOUS MALNUTRITION) In this form of severe malnutrition, the child is severely wasted and has the appearance of “skin and bones”. The child’s face looks like an old man’s because of loss of facial subcutaneous fat, but the eyes may be alert. The ribs are easily seen. There may be folds of skin on the buttocks and thighs that make it look as if the child is wearing “baggy pants.” Weight-for-age is likely to be very low. Figure 5.1 Marasmus

WHO (2008)1 KWASHIORKOR (OEDEMATOUS MALNUTRITION) In this form of severe malnutrition, the child’s muscles are wasted, but the wasting may not be apparent due to generalised oedema (swelling from excess fluid in the tissues). The child is withdrawn, irritable, obviously ill, and will not eat. The face is round (because of oedema) and the hair is thin, sparse and sometimes discoloured. The skin has symmetrical discoloured patches, which later cracks and peels off. A child with kwashiorkor will usually be underweight, but the oedema may make the child appear overweight; it is very important, therefore, to conduct this visual assessment of the child’s health as well as weigh the child and conduct a growth assessment.


MARASMIC KWASHIORKOR Kwashiorkor and marasmus are distinct conditions, but in communities where both occur, cases of severe undernutrition often have features of both. For example, a child may have severe wasting as seen in marasmus, along with the skin and hair changes or oedema typical in kwashiorkor. OEDEMA OF BOTH FEET Oedema of both feet is a sign that a child needs referral, even if other signs of kwashiorkor are not present. The oedema must appear in both feet. (If the swelling is in only one foot, it may just be a sore or infected foot.) To check for oedema, the healthcare worker should grasp the foot with her or his hand and gently press the thumb into the top of foot for a few seconds. The child has oedema if a pit (dent) remains in the foot when the thumb is lifted. A child with oedema of both feet is automatically considered severely underweight, regardless of what the scale shows. Weigh and measure the child, and note in the Road to Health booklet. If a child has marasmus, kwashiorkor, or oedema of both feet, make note in the Road to Health booklet. When plotting the child’s measurements, indicate on the graphs, near the relevant points, if the child has oedema. Refer the child for specialised care.

MEASURING WEIGHT 3


To encourage discussion, ask participants to refer to Figure 5.3: Paediatric beam balance scale with the picture of weighing equipment. Ask participants: Has anyone used any of these scales? If so, which ones? How do you weigh a child with this scale? What, if any, problems have you experienced with this scale? How did you deal with that problem?

Regardless of the growth indicator used, it is important to have simple and accurate equipment for weighing children. There are a few things to consider when weighing a child: Handle the child gently so as not to frighten the child. Explain to the caregiver what you are doing — it is important that you explain what

is going on, why and how you are taking the weight and how she might assist you. Equipment must be maintained in good and accurate working order — ensure scales

are calibrated daily and serviced frequently (as per clinic SOP).

Figure 5.2: Oedema of the feet

WHO(2008)2


Children less than two years of age: Until the age of two years, children should be weighed nude, with nappy off, on baby

scales. A weight taken without clothing (including nappy) is most accurate. Let the caregiver undress the child. The caregiver should hold the child during much of the process, only letting go for

the measurement. Take the measurement accurately but quickly so that the unclothed child does not get

too cold. Make sure the main beam weight is fully in the groove of the scale corresponding to

a whole number to ensure accuracy. If removing the nappy is not possible, or if the infant will not stay still enough to take

an accurate measurement, the caregiver and baby can be weighed together — see the procedures in the next section “Electronic scale”.

Children over two years of age: Children should be weighed in light clothing, without shoes on a standing or sitting

scale. Disabled children unable to sit or stand should be weighed in light clothing on a

hoist scale if available. If not available the parent and child can be weighed together as per the procedures below.

ELECTRONIC SCALE An electronic scale can be used in the absence of a paediatric beam scale. The procedures for this include: A. Take the weight of the caregiver and child (the child should have clothing, including

nappy, and blanket removed). B. Take the weight of the caregiver. C. “A” (Caregiver + child’s weight) minus “B” (caregiver’s weight) = weight of child When removing the nappy is not possible replace “A” with the weight of the child with nappy and replace “B” with the weight of just the nappy. Figure 5.3: Paediatric beam balance scale

WHO (2008)4


MEASURING LENGTH AND HEIGHT5


To encourage discussion, ask participants: Have you ever measured an infant’s length or child’s height? Do you plot length/height? If so, what chart do you use?

Depending on a child’s age and ability to stand, measure the child’s length or height. A child’s length is measured lying down (recumbent). Height is measured standing upright. If a child is less than two years old, measure length while the child is lying down. If the child is aged two years or older and able to stand, measure standing height.

LENGTH Use a length board placed on a flat, stable surface, as shown in Figure 5.4 Measuring

length. Cover the length board with a thin cloth or paper. Explain to the caregiver that she or he will need to place the baby on the length

board herself and then help to hold the baby's head in place while you take the measurement. Show the caregiver where to stand when placing the baby down, i.e. opposite you, on the side of the length board away from the tape. Also show the caregiver where to place the baby’s head (against the fixed headboard) so that she or he can move quickly and surely without distressing the baby.

When the caregiver understands your instructions and is ready to assist, move quickly before the baby becomes agitated.

Ask the caregiver to lay the child on her or his back with the head against the fixed headboard, compressing the hair.

Quickly position the head so that an imaginary vertical line from the ear canal to the lower border of the eye socket is perpendicular to the board. (The child’s eyes should be looking straight up.) Ask the caregiver to move behind the headboard and hold the head in this position.

Check that the child lies straight along the board and does not change position. Shoulders should touch the board, and the spine should not be arched. Ask the caregiver to inform you if the child arches the back or moves out of position.

Hold down the child’s legs with one hand and move the footboard with the other. Apply gentle pressure to the knees to straighten the legs as far as they can go without causing injury. Note: it is not possible to straighten the knees of newborns to the same degree as older children.

If a child is extremely agitated and both legs cannot be held in position, measure with one leg in position.

While holding the knees, pull the footboard against the child’s feet. The soles of the feet should be flat against the footboard, toes pointing upwards. If the child bends the toes and prevents the footboard from touching the soles, scratch the soles slightly and slide in the footboard quickly when the child straightens the toes.

Read the measurement and record the child’s length in centimetres to the last completed 0.1 cm in the chart.

If a child aged two years or older cannot stand, measure length and subtract 0.7 cm to convert it to height.


Figure 5.4 Measuring length

Figure 5.5: Measuring tape

WHO (2008)6 Measuring tape: The numbers and longer lines indicate centimetre markings. The shorter lines indicate millimetres. HEIGHT Ensure that the height board is on level ground, as in Figure 5.6 Measuring height.

Check that shoes, socks and hair ornaments have been removed. Ask the caregiver to assist you and kneel to get down to the level of the child. Help the child to stand on the baseboard with feet slightly apart. The back of the

head, shoulder blades, buttocks, calves and heels should all touch the vertical board. This alignment may be impossible for an obese child, in which case, help the child to stand on the board with one or more contact points touching the board. The chest area should be balanced over the waist, i.e., not leaning back or forward.

Ask the caregiver to hold the child’s knees and ankles to help keep the legs straight and feet flat, with heels and calves touching the vertical board. Ask her to focus the child’s attention, soothe the child as needed, and inform you if the child moves out of position.

Position the child’s head so that a

horizontal line from the ear canal to the lower border of the eye socket runs parallel to the baseboard. To keep the head in this position, hold the bridge between your thumb and forefinger over the child’s chin.

If necessary, push gently on the tummy to help the child stand to full height.

Still keeping the head in position use your other hand to pull down the headboard to rest firmly on top of the head and compress the hair.

Read the measurement (the last line you can actually see) and record the child’s height in centimetres to the last completed 0.1 cm.

If the child whose height you measured is less than two years old, add 0.7 cm to the height and record the result as length.

Figure 5.6 Measuring height


MEASURING HEAD CIRCUMFERENCE7


To encourage discussion, ask participants: Have you ever measured head circumference? If so, what chart do you use to plot head circumference? (Note: the Road to

Health booklet does not currently include a chart for plotting head circumference.)

Measure head circumference at every visit until 24 months of age. Head circumference is the last measurement to be affected in a malnourished child. This measure reflects brain size and is used to screen for potential developmental and health problems — including encephalopathy in HIV-infected children. Refer for assessment of health or developmental risk if head circumference measurements suggest growth faltering or if a child measures below the -2 z-score line (which corresponds to roughly three percent) or above the +2 z-score line (roughly 97%). For further reference see Appendices 4 and 5. PROCEDURE Use a paper measuring tape to avoid stretching as can happen with cloth tape. Remove any braids, plaits, barrettes or other hair decorations that will interfere with

the measurement. Allow the infant or child to sit

comfortably in the arms or lap of a caregiver.

Position the tape just above the eyebrows, above the ears, and around the biggest part of the back of the head, as in Figure 5.7 Measuring head circumference. The goal is to locate the maximum circumference of the head.

Pull tape snugly to compress the hair and underlying soft tissues.

Read measurement to the nearest 0.1 cm and record.

Reposition tape and re-measure head circumference. If measurements do not agree within 0.2 cm, then reposition tape and re-measure a third time. Record the average of the two measures in closest agreement.

Figure 5.7 Measuring head circumference

Royal College of Paediatrics and Child Health 20098


MEASURING MID-UPPER ARM CIRCUMFERENCE9


To encourage discussion, ask participants: Have you ever measured mid-upper arm circumference? If so, which tape do you use to measure MUAC? (Note: the Road to Health

booklet does not include a chart for tracking MUAC.) While not a required part of routine growth monitoring, measuring mid-upper arm circumference can be a reliable guide to identifying severe wasting. Children aged 6-60 months with a MUAC under 115 mm are a much greater risk of death compared to those with a MUAC above 115mm. MUAC is less accurate than weight-for-height for measuring current malnutrition (wasting) and malnutrition over time. However, it is an excellent tool for rapid screening, when applicable. PROCEDURE Determine the mid-point between the left elbow and the left shoulder. The arm should be relaxed and hanging at the side of the body. Place the tape

measure around the arm. Measure the MUAC while ensuring that the tape is neither too tight nor too loose. Read the measurement to the nearest 0.1 cm or 1mm from the tape and record. If using a 3-colour tape: Green zone means the child is properly nourished; Yellow

zone means that the child is at risk of malnutrition; Red zone means that the child is acutely malnourished. Check for clinical signs of kwashiorkor or marasmus if the child is in the yellow or red zone.

If using a 4-colour tape: Green zone means the child is properly nourished; Yellow zone means that the child is at risk of malnutrition; Orange zone means that the child is moderately malnourished; Red zone means that the child is severely malnourished; clinical signs of kwashiorkor or marasmus may be apparent.

GROWTH CHARTS


Refer to the Road to Health booklet if you have one (the growth charts appear in Appendices 2 and 3). To encourage discussion, ask: Who has used the Road to Health growth chart? What is its purpose? How do you use it? What does each of the five growth curves — the curves going up and across the

chart — mean? ROAD TO HEALTH BOOKLET All children are issued a Road to Health booklet at birth or their first well-child visit. The Road to Health booklet includes space to record the child’s demographic information, immunisations, Vitamin A supplementation, deworming, TB status, results


of routine visual and hearing screening, PMTCT information, growth charts (included in Appendices 2 and 3), BMI tables, infant and young child feeding information, information on hospital admissions and a place to record visit notes. The Road to Health growth charts include graphs to chart weight-for age and weight-for-length/height for both boys and girls (the boys’ chart and the girls’ chart are now gender specific). If used properly, the Road to Health booklet promotes the healthcare worker-caregiver relationship, improves the decision-making process and helps to identify children needing extra care. GROWTH CHARTS —HEAD CIRCUMFERENCE Use the standard government or agency head circumference growth chart. If a standard growth chart is not available use the appropriate growth chart from WHO. Although the HC growth charts appear in Appendices 4 and 5, it is preferable to print copies of the standard growth chart directly from the WHO website. Growth charts can be downloaded from the WHO website10. The “Boy’s Growth Record” and “Girl’s Growth Record” growth charts are near the end of either document. Select the appropriate growth chart based on the child’s sex and age at the time of visit. PLOTTING WEIGHT, LENGTH/HEIGHT AND HEAD CIRCUMFERENCE Plotting is necessary to assess whether the child is growing or gaining weight at an adequate rate. The steps to plot weight-for-age, weight-for-length/height and head circumference are in Table 5.2. Table 5.2 Plotting growth charts Step

1 Obtain measurement Obtain accurate weights, length/height and head circumference. When

weighing and measuring children, follow procedures that yield accurate measurements and use equipment that is well maintained.

Step 2

Select the correct growth chart Select the appropriate chart based on sex of the child. The weight and

length/height growth charts can be found in the Road to Health booklet. Head Circumference can be requested through your clinic manager (or downloaded from the WHO website).

Step 3

Complete the necessary charts Ensure the child’s Road to Health booklet or other applicable medical chart

is completed with the appropriate demographic, social and clinical information.

Step 4

Record measurement and date Record today’s date, child’s exact age today, weight and length/height on

page 2 or 3 of the Road to Health booklet. Weight: record the child’s weight and today’s date in the space corresponding

to the child’s age in months along the lower horizontal axis near the bottom of the appropriate page in the Road to Health booklet (pages 14–15).

Length/height: although there is no dedicated space for it, if it makes it easier to plot (Step 5), you may record the child’s length/height and today’s date in the margin just below “Length/height in centimetres (cm)” near the bottom of page 17 and 18 in the Road to Health booklet.


Head circumference: although there is no dedicated space for it, if it makes it easier to plot (Step 5), you may record the child’s head circumference and today’s date in the margin just below the child’s age in weeks/months below the lower horizontal axis of the head circumference-for-age growth chart.

Step 5

Plot the measurement Weight and head circumference:

Find the vertical line that corresponds to the child’s age (in week, months or years) using the ages listed along the lower horizontal axis. Use a straight edge ruler to draw a vertical line up from that point.

Find the weight or HC measurement on the vertical axis (on the right or left side of the chart). Use a straight edge ruler to draw a horizontal line across from that point until it intersects the vertical line.

Make a small dot where the two lines intersect. Weight-for-length/height:

Find the vertical line that corresponds to the child’s length/height in centimetres using the centimetres listed along the lower horizontal axis. Use a straight edge ruler to draw a vertical line up from that point.

Find the weight measurement on the vertical axis (on the right or left side of the chart). Use a straight edge ruler to draw a horizontal line across from that point until it intersects the vertical line.

Make a small dot where the two lines intersect. Step

6

Compare Compare today’s measurement with the measurements from previous visits

to identify any major shifts in the child’s growth pattern and the need for further assessment.

Step 7

Interpret the plotted measurements Children who are well and healthy should gain weight at a predictable rate

and follow a path parallel to the 0 line (median). The line labelled “0 line (Median)” in the middle of the growth chart is the

median line which is, generally speaking, the average. The other lines (2 or 3 line and the -2 and -3 lines), indicate distance from the

average. These lines as well as the median are also referred to as z-score lines.

About 95 out of 100 children’s measurements will fall between the 2 and -2 lines.

The growth curve of a normally growing child will usually follow a z-score line that is roughly parallel to the median. The track may be above or below the median.

Step 8

Evaluating growth Any quick change in trend (the child’s curve veers sharply upward or

downward from its normal track) should be investigated to determine its cause and remedy any problem.

A flat line indicates that the child is not growing. This is called stagnation and should also be investigated.

A growth curve that no longer follows the line that the child normally follows, or an inconsistent pattern, may indicate risk. Interpret risk based on the weight status of the child according to the growth chart (see also Table 5.3) and by how sharply the child’s growth pattern line rises or falls on the chart.


INTERPRETING GROWTH CHARTS


Discuss how to interpret information from growth monitoring. Start by introducing Table 5.3: Interpreting points on growth charts explaining that a point that falls below the – 2 or -3 z-score line suggests that an immediate intervention is necessary. Additional information on z-scores can be found in Appendix 1.

Next ask participants to discuss how to interpret a child’s growth curve, which is a set of measurements taken over a period of time that are plotted to compare a child’s growth to expected growth. Refer to Figure 5.9: Diagrams of Adequate Growth and Growth Faltering and review the four growth lines/curves: Adequate weight gain Early growth faltering Prolonged growth faltering Severe growth faltering

Give participants a minute or two to look at the diagrams and then ask: Have you ever observed a child’s growth similar to any of the diagrams in Figure

5.8? What about Figure 5.9? How would you advise the parent of the child whose growth is represented by the

first figure — adequate weight gain? What referrals, if any, would you provide? [Answer: this child’s weight gain is adequate, compliment the parent note that this is exactly what we like to see, no nutrition intervention is necessary unless there are other issues.]

How would you advise the parent of the child whose growth is represented by the 2nd figure — “Early growth faltering in presence or absence of illness”? What referrals, if any, would you provide? [Answer: if this child has no obvious reason to explain growth faltering — e.g. acute illness — undertake a nutrition assessment to identify the underlying issues before growth faltering affects development. Provide education, support and referrals to prevent any further growth faltering.]

How would you advise the parent of the child whose growth is represented by the 3rd figure — “Prolonged growth faltering”? What referrals, if any, would you provide? [Answer: undertake a nutrition assessment to identify underlying causes for growth faltering, it is important to act quickly and refer for medical care and social services before hospitalisation is required.]

How would you advise the parent of the child whose growth is represented by the 4th figure — “severe growth faltering”? What referrals, if any, would you provide? [Answer: this depends on the clinical presentation of the particular case, but there is a good chance that this child might require hospitalisation at this point to both address the underlying case of the malnutrition and to treat the undernutrition. Provide follow-up care.]


When a child is calorically deprived, the first thing they lose is weight. Acute caloric deprivation and the resulting weight loss leads to wasting. Prolonged caloric deprivation leads to slowed growth and the child will become stunted. Finally, the growth of the head circumference will also slow down. Identifying the signs of growth faltering and intervening at an early stage is crucial to ensuring the health of children with HIV. Early weight loss or inadequate rate of growth can be identified by observing the child’s weight, length/height and HC at a single point in time and over time. If any single measurement falls below the – 1 z-score line (whether weight-for-age or weight-for-length/height) should be further assessed and an intervention developed based on a nutrition assessment. Children who fall below the – 3 line require hospitalisation. The nutrition assessment, discussed further in the next Session, will provide insight on whether there are specific areas of need or if simple caloric supplementation is required. Table 5.3: Interpreting points on growth charts

Growth indicators z-score

Weight-for-age

Weight-for length/height

BMI-for age Head circumference

Above 3 Obese Obese Macrocephaly Above 2 Overweight Overweight Possible

macrocephaly Above 1

See note 1

Possible risk of overweight (see note 2)

Possible risk of overweight (see note 2)

0 (median) Below – 1 Below – 2 Underweight Wasted Wasted Possible

microcephaly Below – 3 Severely

underweight (See note 3)

Severely wasted

Severely wasted

Microcephaly

Notes: 1. A child whose weight-for-age falls in this range may have a growth problem, but this

is better assessed from weight-for-length/height or BMI-for-age. 2. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line

shows definite risk. 3. This is referred to as very low weight in IMCI training modules. (Integrated

Management of Childhood Illness, In-service training. WHO, Geneva, 1997). For more information on z-scores, see Appendix 1.

Measurements in the shaded boxes are in the normal range.


GROWTH FALTERING

Growth faltering refers to the rate of growth: A flat or falling growth curve in a child is abnormal and indicates growth faltering, even if the child is not underweight. When weight “falters” or the growth curve “flattens” and is no longer parallel to the z-score line, there is a need for clinical and nutritional intervention. See Figure 5.8: Growth curve indicators. Figure 5.8: Growth curve indicators11


Figure 5.9: Diagrams of Adequate Growth and Growth Faltering

Adequate Weight Gain

Early Growth Faltering In Presence or Absence of Illness

Prolonged Growth Faltering

Severe Growth Faltering (Weight loss)


Session 5.8 of this module will focus in more detail on interventions for HIV-specific symptoms and growth problems.


Introduce and facilitate Exercises 1 and 2.

Exercise 1: Growth Faltering Plotting Exercise Individual work followed by large group discussion

Purpose To review plotting on the Road to Health growth chart and to identify growth faltering.

Duration 15 minutes

Advanced Preparation

On a flip chart, write the following age and weights: Birth weight 2.5kg 2 months 4kg 4 months 5.5kg 6 months 6.7kg 8 months 7kg 10 months 6.8kg

Introduction This exercise will give participants an opportunity to plot growth on the Road to Health booklet and to identify growth faltering.

Activities Ask participants to take out their copies of the Road to Health growth chart (Appendices 2 and 3), and Table 5.2 Plotting growth charts.

Ask the participants to take 10 minutes and plot baby Naledi’s growth on the correct Road to Health growth chart. [Correct chart is the girl’s growth chart.]

Walk around the room and offer help to the groups as needed. Ask the participants to describe Naledi’s growth trend from birth to

10 months of age. [Answer: Naledi gained weight until the 8 month visit, but starting from the 6 month visit you can see that her growth is flattening and no longer parallels the 0 line (median); by the 10 month visit her growth touches the – 2 z-score line.]

Remind participants that Naledi’s results underscore the importance of a growth chart. If the weight was not plotted on a growth curve, this baby’s growth faltering might not have been detected until severe growth faltering occurred.

Point out to participants that, as in Naledi’s case, children may gain weight but still have growth failure.

Note that participants will discuss the management of growth faltering later in this module.

Debriefing This exercise provided experience detecting growth faltering and reviewed plotting on the growth curve. The exercise illustrates the importance of looking at a child’s growth curve. Allow participants


time to comment and ask questions about growth monitoring on the Road to Health booklet.

Remind participants that growth monitoring is important for all children.

Exercise 2: Growth Plotting Exercise Small group work: participants break into groups of 3 or 4

Purpose To practise plotting on the Road to Health growth chart and to identify growth problems.

Duration 30 minutes

Materials Growth Monitoring Case Studies Supplement

Introduction This exercise will give participants an opportunity to plot growth on the Road to Health booklet and to identify growth faltering.

Activities Ask participants to break into groups of three to four. Assign each group one of the following cases from the Growth

Monitoring Case Study Supplement: Agnes, Hendrick, Kagiso, Palesa, Precious, Ruth Sipho, Thabo.

Have the groups take 10 minutes to plot the measurements and assess the child’s growth.

Bring the groups together and have each group present their case study. In the event that more than one group has the same case, allow them to present together. This should take approximately 15 minutes.

Debriefing This exercise provided experience detecting growth faltering and reviewed plotting on the growth curve. The exercise illustrates the importance of looking at a child’s growth curve. Allow participants time to comment and ask questions about growth monitoring on the Road to Health booklet.

Remind participants that growth monitoring is important for all children.


SESSION 5.2 NUTRITION ASSESSMENT FROM BIRTH THROUGH ADOLESCENCE IN THE CONTEXT OF HIV

SESSION DURATION 1 hour 15 minutes

SESSION LEARNING OBJECTIVES Describe methods for assessing nutritional status. Discuss clinical signs associated with undernutrition.


Step 1: Review the learning objectives for this session. Step 2: Introduce nutrition assessment by discussing its purpose. Discuss

why children living with HIV are at high risk for undernutrition and growth problems.

Step 3: Then discuss the goals and steps in the nutrition assessment. Next focus on the type of client interviews used to find out more about the client and their home situation.

Step 4: Discuss clinical signs associated with undernutrition. Step 5: Facilitate Exercise 3: Client Interview. Key points: This session provides an overview of nutrition assessment. The key

points: A nutritional assessment — which uses medical and social history,

information from the physical examination, information from client interviews and laboratory investigations — provides valuable information about a child’s dietary intake and food norms and provides clues to addressing slowed growth rates.

In children with HIV, growth faltering may indicate disease progression or treatment failure.


INTRODUCTION TO NUTRITION ASSESSMENT


To encourage thought on this topic, ask participants: What is ‘nutrition assessment’ and ‘nutritional status’? How is the nutritional status of children assessed at your facility? Who does what?

How often? Why do you think children living with HIV are at high risk for undernutrition?

Allow participants to discuss; write their answers on a flip chart. When it is determined that a child’s growth is faltering, the healthcare worker should conduct a comprehensive nutrition assessment, plan an intervention, provide support and make referrals as necessary. An assessment can provide clues on the nutritional and other medical interventions needed to address growth faltering. Given the environmental context in which many of these children live, which may include lack of access to sufficient food and clean water, the nutrition assessment includes an investigation of barriers to adequate nutrition including access to food, nutritional intake and history including HIV and non-HIV-related issues. Children living with HIV are at high risk for undernutrition and growth problems for a number of reasons: Don’t get enough food to make up for increased energy needs due to HIV plus

normal growth and childhood activity Poor absorption (malabsorption) of nutrients Increased metabolism — HIV infection places increased energy demands on the

body Chronic diarrhoea Effects of ARVs

ARVs may change the way nutrients are absorbed, used or removed by the body.

The side effects of some ARVs can cause loss of appetite, or change in taste, diarrhoea, or change food absorption.

ARV side-effects such as fatigue, depression, loss of sleep and pain may lower food intake.

Nutrition assessment A nutrition assessment is an in-depth evaluation of a client’s food and nutrient intake, social and economic situation, and medical history. Once the data on an individual is collected and organised, the healthcare worker can assess and evaluate the nutritional status of that person. The assessment leads to an intervention designed to help the client either maintain the assessed status or attain a healthier status. Nutritional status is the condition of the body as a result of the intake, absorption and use of nutrition and the influence of disease-related factors.


Malnutrition: an imbalance of energy, protein and/or essential vitamins and minerals (known together as micronutrients) necessary to maintain healthy tissues and organ function. It includes both undernutrition (which results in underweight, wasting and stunting) and overnutrition (which results in overweight and obesity). Undernutrition: a lack of energy, protein and/or essential vitamins and minerals either due to not getting enough of each in food, the body being unable to process the food correctly (malabsorption and mal-utilisation), or the body getting rid of food or nutrients too quickly. Undernutrition can result in micronutrient deficiencies and/or the following (see also Table 5.3: Interpreting points on growth charts): Underweight or severely underweight (below -2 or -3 z-score line in weight-for-age). Wasted or severely wasted (below the -2 or -3 z-score line in weight-for-

length/height or BMI-for-age) In children with HIV, growth faltering may be the first sign of disease progression and requires immediate intervention. For children already on ARV therapy, growth faltering may be an indication of the need to review ARV adherence, change ARV regimen or refer the child for supplemental food assistance. Given the accelerated pace of HIV progression among children (50% of whom will die before their second birthday if they do not have access to care and treatment), aggressive medical support in conjunction with nutritional support are important to limit the long-term impact of the virus on growth and development.

STEPS IN THE NUTRITION ASSESSMENT


To encourage discussion ask participants: What are the steps in a nutrition assessment? What would you want to ask your client to find out why a child is undernourished? What would you ask to find out what the child is eating? What would you ask to find out about household food security? What would you ask to find out more about activity patterns? What would you ask to find out if the child’s feeding skills are age-appropriate? What would you ask to find out what other changes are occurring in the home that

might affect nutritional intake? Information from the nutrition assessment matched with growth evaluation can: Provide insight into the causes of undernutrition. Provide information for the development of an intervention, including on-going

support. Serve as a mechanism for evaluating nutritional recommendations.


The goals of a nutrition intervention are: Protect and improve nutritional status (improve weight gain, restore growth by

suggesting individualised meal plans and advise on changing lifestyles that negatively affect energy and nutrient intake)

Ensure adequate nutrient intake (improve eating habits and replenish stores of essential nutrients to improve immunity and prevent infections)

For children on ARVs or other medications: promote and improve adherence to treatment

Improve body composition (promote regular exercise to preserve muscle mass)

Prevent food-borne illnesses Enhance quality of life (treat opportunistic infections and manage symptoms

affecting food intake) Provide comfort (advise on treating opportunistic infections, counsel to modify diet

according to symptoms and encourage eating and physical activity) The assessment should be conducted by a physician, nutritionist, nurse or other healthcare worker who is familiar with the signs and symptoms of undernutrition and delayed growth. Frequency of these assessments will vary based on the child’s nutritional status and the underlying reason for the problem (if a problem is identified). Well-nourished children can be assessed according to the routine schedule for well-child visits. The assessment can be done with the participation of older children in addition to the caregiver. On the other hand, a young child who is discharged from the hospital after treatment for severe malnutrition needs early and frequent follow-up until stable, normal growth is well established. In general, after intervention for a moderately malnourished child, follow-up could take place in one or two months. Below are the recommended steps and rationale for conducting a comprehensive nutrition assessment for a child whose growth is faltering as determined by the growth monitoring. 1. Take medical and social history. It is important to understand the child’s health-

related history, including illnesses that affect nutritional status (such as frequency and severity of diarrhoea, oral thrush, recurrent chest infections, fever, malaria and parasitic infections). In addition to HIV, ask about current or recent illnesses, allergies, family history of disease (including HIV and TB), medication history, parental socioeconomic status including ability to purchase food, etc.

The medical history of both parents, including HIV status and any other chronic condition, can help interpret growth monitoring information and affect decisions about laboratory tests requested. The mother’s HIV status affects the child’s risk of HIV and infant feeding recommendations. If mother is breastfeeding, assess her nutritional intake for her own health and to ensure adequate nutrition for maintenance of milk supply. Child-headed households are particularly vulnerable to undernutrition due to their likely insecure financial situation, challenging social status and possible difficulties

Intervention and support Intervention is a response to a problem. Intervention is also referred to as a care plan. Support refers to on-going or long term assistance to resolve a problem. Clinical problems are usually addressed through both intervention and support.


accessing adequate food supplies, support and other services. Understanding the family’s make-up and circumstances will help identify nutritional issues.

Conduct physical examination with specific attention to the signs of malnutrition (see 2. Table 5.5: Clinical signs associated with malnutrition). 3. Conduct dietary and nutritional assessment and order laboratory tests as

needed. Talking with children and their parents/caregivers about their diet and food practices provides valuable information about factors that affect a child’s nutritional status and creates opportunity to offer education and support based on an understanding of the family’s lifestyle.

The interview is a critical component of the overall assessment of nutritional adequacy for the child, complements the clinical findings, provides insight into internal family dynamics, and allows for the development of trust between the healthcare worker and caregiver. Without this relationship, important information that may be critical to providing appropriate care, e.g., sharing medication or rationing formula or other food supplements amongst family members, may not be divulged to the healthcare worker. Table 5.4: Nutrition assessment client interview provides a summary of the client interviews as a key to the nutrition assessment.

Laboratory investigation may be indicated to determine the underlying cause of the malnutrition or identify the degree of malnutrition (micronutrients). For example, haemoglobin levels provide information about whether or not a child is anaemic; anaemia may be the result of inadequate iron in the diet. Parasites in stools can confirm or deny a parasitic infection — undernutrition and parasitic infections are closely linked. For children with HIV infection, CD4 testing provides information on disease progression and ARV therapy eligibility. CD4 and viral load testing together can give insight into possible treatment failure.

4. Develop a nutritional care plan. The nutritional care plan outlines the

interventions required to address undernutrition as determined by the growth monitoring. The care plan is based on the medical history, clinical examination and nutrition assessment (the three steps, above). The nutrition care plan identifies the family’s counselling and educational needs and the goals of nutrition therapy.

5. Organise the discharge plan. The discharge plan includes documentation of the

assessment, referrals (if needed) and ongoing support requirements (including follow-up appointments).


Table 5.4: Nutrition assessment client interview Purpose and description Investigation Intervention

Household food security12

Provides information on access to sufficient food. If there is reason to

suspect that a family does not have access to enough food (and the diet history did not provide such information), ask about food security.

Ask: How many meals do you eat on a typical day? How often in a week do you feel there isn’t enough food in the house to feed everyone?

Ask: When there is meat, does everyone get a share? Who normally get the most full-stomach meals?

Ask: Did anyone in the household eat any of the following foods yesterday (Group 1: vegetables or fruits; Group 2: Meat, fish, eggs; Group 3: Cheese, yogurt, milk, milk product; Group 4: Foods made with oil, fat or butter)? If not, why not?

Based on dietary intake, make recommendations to help with food budget, e.g., use more beans and less meat.

Recommend exclusive breastfeeding to six months of age.

Help to identify social support for caregivers and school feeding projects.

If eligible, refer to a food supplementation programme.

Dietary intake or diet history

Provides information about the quantity and quality of a child’s diet and insight into the family’s food preparation and eating habits. The diet history is usually administered in either of the following ways: Healthcare worker asks

client to report on what she or he ate and drank for the past 24 hours (24-hour recall) while the healthcare worker records the intake. This assessment is useful for clients who cannot or do not want to keep a food log.

Food-frequency questionnaire, in which

Ask: Who usually buys or produces the food that you eat in your house? Who prepares the food? Who prepared breakfast this morning? How about lunch/dinner yesterday?

Ask: Please tell me what and how much your child ate and drank all day yesterday.

Ask: What did your child eat for breakfast yesterday? What did she drink? What snacks did she eat after breakfast and before lunch? What did she drink? (Continue to ask similar questions about lunch, dinner as well as afternoon and

Based on dietary history, provide education to support consumption of sufficient and varied diet, e.g., start a garden, eat more fruit, add high calorie ingredients to food (butter or margarine, vegetable oil, full cream milk powder, peanut butter).

If needed, provide support to address barriers to producing, purchasing and/or preparing healthy food.

Recommend exclusive breastfeeding to six months of age.

Discuss introduction of complementary foods


the client is asked about intake of specific foods, such as amount of meat or dairy consumed in a specific time period.

A food log or diary where the client keeps a record of her or his diet for several days (if client can read/write and has time to keep a food log).

evening/night time snacks.)

Ask: How big was the portion you ate? How was it cooked (boiled, fried, baked)? Did you add anything to it, such as butter, peanut butter, jam or condiments (tomato sauce or pickle)?

Ask: What traditional remedies is your child taking?

from 6 months Give information on

safe food handling. Provide education on

the prevention of infections, especially diarrhoea.

If available and indicated by laboratory tests and/or dietary history, give, prescribe or refer for supplements (e.g., iron).

Use this opportunity to discuss good hygiene, immunisations and vitamin A supplements.

Activity patterns

Informs assumptions about food adequacy; changes in activity patterns can give insight into health and illness. Interview caregivers

about their child’s activity levels and activity patterns including lethargy.

Document caregiver responses so that activity patterns can be compared between visits.

Ask: What activities does your child do? Does your child play sports, run around, play with other children?

Ask: Have you noticed any changes in play or activity?

Use this opportunity to discuss the important of regular exercise to develop and maintain strong muscles, improve sense of well-being, fight and avoid infections

Use this information in combination with laboratory results and information from the diet history to provide appropriate recommendations and/or referrals.

Feeding skill development

Evaluates if the child is able to adequately consume a varied, age-appropriate diet. Ask about and provide

support with weaning, transitioning to complementary foods, feeding skills, advancing food textures (when and how).

See also Table 5.6:

Zero-six months, ask: What are you feeding your child? What else is your baby taking? How do you feed your child (cup fed, bottle fed, spoon fed)? What, if any, problems have you encountered?

After six months, ask: What are you feeding your child? What

Provide infant and young child information, education and support, as needed.

Provide referrals for specialist support, as needed.

Discourage mixed feeding before six months of age (see Module 4).


Sequence of infant feeding development and feeding skills.

else is your baby taking? How do you feed your child (cup fed, bottle fed, spoon fed, self feed)? How do you prepare baby’s foods? How is baby tolerating these foods? What, if any, problems have you encountered?

Psychosocial status

Provides information on psychosocial issues that may impact on dietary intake. Social changes impact

upon diet. For example, a child of an ill mother may lose weight because the mother is too ill to prepare the type of meals the child is used to.

Determine whether there have been major changes for the child or family. For example, ask: Has your child

experienced any major changes at home or school?

Have there been any major life changes experienced by others in the home (new baby, divorce/separation, new job, illness, death, etc)?

How has your (the caregiver) health been since the last visit?

How are other caregivers in the house?

If appropriate, recommend foods that are quick and easy to prepare.

Provide other support around underlying social issues.

Refer for follow-up counselling.

Refer to the Medical Doctor or Clinical Nurse Practitioner if needed.

Nutrition-related interventions, including nutrition counselling in children living with HIV, are described in Sessions 5.7 and 5.8.

CLINICAL SIGNS OF MALNUTRITION


To encourage discussion ask participants: What are some of the clinical signs of malnutrition that you have seen in your clinic?

Healthcare workers should be familiar with the more frequently seen malnutrition-related conditions in their local areas, and should be provided with training on how to care for and treat these ailments. Some of these conditions are due to caloric deficiencies, and may be corrected by the food supplements often provided by nutrition programs. However, many conditions are due to deficiencies in proteins and micronutrients, which may be more difficult to address at the primary care level. For example:


Deficits in iron cause low haemoglobin levels and retarded growth of the blood-forming organs, as well as have negative effects on cognitive ability.

Deficits in certain micronutrients such as vitamin A, vitamin C, vitamin D, zinc, selenium, copper and iron impair immune function. Impaired immunity increases risk of opportunistic infections.

Protein deprivation decreases many body functions including the production of molecules released by immune cells that are needed to fight infection.

Where a child’s condition is due to deficiency in protein and micronutrients, the healthcare worker may prefer to refer the child for further care. Session 5.7 provides information on the process of referrals. Common signs of malnutrition include enlarged abdomen, thinning or discoloured hair, and discolouration of the skin. Table 5.5: Clinical signs associated with malnutrition lists in more detail common clinical signs associated with malnutrition and the specific causes of these conditions. Table 5.5: Clinical signs associated with malnutrition Area of Examination

Findings Possible Cause

Underweight, short stature Deficiency of calories Oedema (swelling) Decreased activity level

Protein deficiency General

Overweight Excess calories Hair Easily plucked; sparse, loss of colour

(pigment); lack of curl; dull, altered texture

Protein deficiency

Abnormal dryness Small, rough bumps caused by skin

plugging up hair follicles (follicular keratosis)

Vitamin A deficiency

Symmetrical dermatitis of skin exposed to sunlight, pressure, trauma

Niacin deficiency

Purplish discoloration (purpura- due to bleeding underneath the skin)

Small red, purple or brown pin-head-sized spots in the skin, usually legs, feet, trunk and arms (petechiae)

Ascorbic acid deficiency

Scrotal, vulval rash (dermatitis) Riboflavin deficiency

Skin (General)

General rash (dermatitis) Zinc, essential fatty acids deficiency

Flaky white scales in the facial lines from the nose to the corners of the mouth (seborrheic dermatitis)

Riboflavin deficiency Skin (Face)

Moon face; diffuse loss of colour (pigment)

Protein deficiency


Decreased tissue Deficiency of calories Subcutaneous tissue Increased tissue Excess calories Nails Spoon-shaped

Flat or even concave in shape, rather than convex (koilonychias)

Iron deficiency

Dry eye (conjunctiva); softening, drying and ulceration of the cornea (keratomalacia)

Vitamin A deficiency

Drying of the conjunctiva of the eye and the development of superficial, irregularly-shaped, foamy gray or white patches called Bitot’s spots

Riboflavin deficiency

Eyes

Circumcorneal injection (enlargement of the blood vessels near the margin of the cornea with reduction in size peripherally)

Riboflavin deficiency

Single or multiple fissures and cracks at the corner of the mouth on one side or both sides, which in advanced stages may spread to the lips and cheeks (angular stomatitis)

Riboflavin, iron deficiency

Lips

Scaling and fissures at the corners of the mouth (cheilosis)

B-complex deficiency

Swollen, bleeding Vitamin C deficiency Gums Reddened gums Vitamin A excess Cavities Fluoride deficiency Mottled, pitted enamel Fluoride excess

Teeth

White spots on teeth (hypoplastic enamel)

Vitamins A, D deficiency

Tongue Swelling or colour change (glossitis) Niacin, folate, riboflavin, vitamin B12 deficiency

Beading of the cartilage between all moveable joints (costochondral beading)

Vitamins C, D deficiency

Softening or thinning of the skull (craniotabes); Unusually prominent forehead (frontal bossing); enlargement of new bone formation areas at ends of long bones (epiphyseal enlargement)

Vitamin D deficiency

Skeletal

Bone tenderness Vitamin C deficiency Decreased muscle mass Protein, calories

deficiency Muscles

Tender calves Thiamin deficiency


Paralysis of eye muscles (opthalmoplegia)

Thiamin, vitamin E deficiency

Neurologic

Lack of coordination of muscle movements (ataxia), sensory loss

Vitamins B12, E deficiency

Underproduction of thyroid hormone (hypothyroidism)

Iodine deficiency

Glucose intolerance Chromium deficiency Altered taste Zinc deficiency

Endocrine and Other

Delayed wound healing Vitamin C, zinc deficiency

Source: Walker and Watkins Eds.13


Introduce and facilitate Exercise 3, which is an opportunity to practise the 24-hour recall. The 24-hour recall is a quick way to learn about the adequacy of a child’s food intake.

Remind participants that the children for whom they will be conducting a nutrition assessment are those whose growth is determined to be faltering. The nutrition assessment is conducted to shed light on the reasons for poor growth.

During this exercise, participants have an opportunity to focus on the initial first step in interviewing a client to get a complete listing of foods eaten in the past 24 hours. In the debriefing, ensure that participants take away an appreciation for the difficulty and complexity of this task.

Participants should save their 24-hour recall because they will need to use them again in Session 5.3, Exercise 4 during which they will evaluate the sufficiency of an individual’s diet.

This particular exercise focuses on interviewing skills, not counselling skills. Nutrition counselling will be discussed in Session 5.7.

Exercise 3: Client Interview Paired group work: participants break into pairs

Purpose To give participants opportunity to practise a nutrition assessment interview. This exercise involves obtaining a 24-hour recall and investigating household food security.

Duration 30 minutes (15 minutes for interviews, 15 minutes debriefing)

Introduction This exercise provides participants an opportunity to obtain information about food security, diet and physical activity. This 24-hour recall will be used in Exercise 4, later in this module. For now, participants are working on obtaining information about their partner’s diet the previous day.

Activities Ask participants to divide into pairs (if there are an odd number of participants, one group can consist of three or the facilitator can pair off with the odd person out). Within the pairs, participants will take


turns interviewing their partner about: Household food security 24-hour dietary recall — what have they consumed (food and

drink) in the past 24 hours, or what did they eat and drink all day yesterday. Ask participants to prompt their partner about important details such as portion sizes, condiments and preparation methods.

Activity patterns — what kind of physical activity do they participate in daily and weekly

Give each group two pages of flipchart paper and a marker. Ask each pair to record the findings from their interview on the flip

chart paper (for use in Exercise 4).

Debriefing This exercise was developed to provide participants with experience collecting diet and activity information. Recalling this type of information is not always easy, and sometimes people find that such questions are difficult to ask.

Ask the group how this experience was for them: What was it like trying to remember everything you ate and drank for a

day? What was it like trying to recall details such as portion sizes, condiments

and cooking method? What was it like to discuss diet and activity with someone else? What have you learned from this exercise that will help you with the

nutrition client interview in your clinic setting? Remind participants that clients sometimes feel vulnerable speaking

with a healthcare worker, particularly if their diet is not ideal. Facilitate a discussion on implementation of nutrition assessment in

our health facilities. Ask: What nutrition assessment services should we offer at each of our facilities? What can we do tomorrow (or when we next go back to work) to initiate

(more thorough) nutrition assessment? What are the barriers to nutrition assessment? How can we address these barriers?

Ask participants to save their 24-hour recall because they will need to use it again in Session 5.3, Exercise 4 during which they will evaluate the sufficiency of an individual’s diet.


SESSION 5.3 NUTRITION REQUIREMENTS AND FEEDING RECOMMENDATIONS FOR HIV-EXPOSED AND HIV-INFECTED CHILDREN

SESSION DURATION 60 minutes (1 hour)

SESSION LEARNING OBJECTIVES Describe nutrition requirements from infancy through adolescence. Describe how to evaluate a 24-hour recall for food group adequacy.


Step 1: Review the learning objectives for this session. Step 2: Provide an overview of the relationship between child growth and

nutrition based on the section entitled, “Growth from infancy through adolescence.”

Step 3: Discuss the “Cycle of nutrition and HIV”. Note that nutrition is important for immune function whether or not the child is on ARV therapy.

Step 4: Discuss the cycle of nutrition and HIV as an introduction to the importance of nutrition during infancy, childhood and adolescence.

Step 5: Discuss growth during infancy including the sequence of infant feeding development and feeding skills.

Step 6: Discuss child and adolescent growth including the quantity and proportion of foods by age.

Step 7: Facilitate Exercise 4, Evaluating Nutrition Adequacy. The exercise provides participants with an opportunity to evaluate a 24-hour recall.


Infants, children, and adolescents need additional calories to support growth. Children with HIV need even more calories to compensate for the toll of HIV infection. If this increased demand is not met, the child will be undernourished.

Poor nutrition weakens the immune system and makes it difficult for children living with HIV to fight infections and to grow properly. Good nutrition, on the other hand, can help children living with HIV fight infections, treat symptoms, maximise benefit from ARV therapy and slow progression of disease.

The 24-hour recall is an important tool to assess diet patterns and nutrient adequacy, particularly among caregivers who cannot


complete diet logs. This method provides valuable insight into actual food intake, and with the inclusion of an evaluation portion, gives the healthcare worker specific guidance on how best to approach and supplement the child’s diet.

GROWTH FROM INFANCY THROUGH ADOLESCENCE


To encourage discussion, ask: Why are nutrition recommendations for children different from adults?

[Answer: Children are still growing therefore their food requirements are higher per kg body weight than a non-pregnant adult.]

Why do children living with HIV have greater nutrition needs than a non-HIV infected child? [Answer: Children living with HIV have increased requirements due to increased losses and increased metabolic demands.]

Adequate food is required to fuel normal growth. In the first year of life a baby requires approximately twice as many calories per kilogram as a male adult; a growing adolescent may require as many calories as a heavy manual labourer. Babies typically double their birth weight by the time they are 5-6 months old. They triple their birth weight by one year. During the second year the rate of growth slows down and appetite decreases. Toddlers and young children experience steady weight gain of about 2 kg per year, and 5-6 cm in height per year. From around 7-10 years children maintain a steady weight gain of about 4 kg/year. During adolescence there is another period of rapid growth: increased body size, shape, and proportions, and development of secondary sex characteristics. Boys develop more muscle and girls more fat.

Figure 5.10: Growth gains14


THE CYCLE OF NUTRITION AND HIV


To encourage discussion, ask participants: How does HIV infection affect nutritional status? How does nutritional status affect HIV infection?

Some studies in South Africa suggest that malnutrition is a major problem among children with HIV and that being wasted or underweight affects up to 50% of children living with HIV.15,16 Low levels of vitamins A, E, B6, B12, and C, beta-carotene, selenium, zinc, copper and iron deficiencies have been reported in adults and children in South Africa. Undernutrition reduces the ability of the immune system to prevent and fight disease, already weakened by the effects of HIV. A number of factors account for reduced food intake in persons living with HIV. These include: Physical issues:

Oral thrush, sores in the mouth or throat Difficulty swallowing Nausea, vomiting, diarrhoea Poor appetite Altered taste of food Fever, pain, malaise — or not feeling well Tiredness and fatigue

Social/family issues:

Parental illness, which prevents food preparation for the child Insufficient money or inability to grow crops Difficulties shopping for, preparing and eating food Family’s lack of awareness of the importance of nutrition, especially when

recovering from infection To help maintain nutrition status, recommendations from the World Health Organisation suggest a 10% increase in energy requirements (an additional snack per day) for asymptomatic HIV-infected children and a 50-100% increase in energy requirements (one and a half to double portions for all three meals or two to three additional meals or large snacks) for the symptomatic HIV-infected infant or child who is experiencing weight loss. Twelve to fifteen percent of calories should be from protein. For a two or three year-old child that means two ounces of protein; a four to eight year-old takes three to four ounces, and a nine-18 year-old takes five to six ounces of protein (one egg or two tablespoons of peanut butter or a thumb-sized piece of meat or cheese equals one ounce). Energy requirements may be less once the child is successfully treated with ARV therapy; however, research related to the energy requirements in children receiving ARV therapy is lacking. A good diet, combined with ARV therapy, can improve nutritional status and help a child stay healthy longer. Because undernutrition is one of the major complications of HIV infection and a significant factor in advanced disease, it is particularly important for children living with HIV to eat a sufficient amount of nutritious foods. Good nutrition


may slow the progress of disease and eventually lead to an increased appetite, as illustrated below in Figure 5.11: Cycle of nutrition and HIV infection. Good nutrition in combination with ARV therapy further accelerates the cycle of recovery. Figure 5.11: Cycle of nutrition and HIV infection17

NUTRITION AND ARV THERAPY

Ensuring adequate nutrition is as important as any clinical or medical intervention; it is the foundation for normal growth and the maintenance of a healthy immune system. Adequate nutrition is as important for children with HIV who are on ART as it is for those not yet eligible for ART — without consistent attention and nutrition supplementation when growth does falter, a child on ARV therapy may be at risk for poor health outcomes. Studies of adults suggest that with use of ART, clients are less likely to progress to a diagnosis of AIDS. Despite viral load reductions, those who lost weight were more likely to die. Even a 1% weight loss was associated with higher risk of death. Moderate to severely malnourished people starting ARV therapy are two to six times as likely to die as those who were not malnourished. Malnutrition decreases survival in patients starting ARV therapy for a number of possible reasons: Impairment of immune system, in turn prolonging the length of time the person is at

risk of opportunistic infections Poor drug absorption


Lower threshold for drug toxicity Symptoms of HIV disease (particularly nausea and vomiting) can affect adherence to

ARV therapy Decreased physical function

GROWTH DURING INFANCY


Provide an overview of nutrition requirements for infants. Also discuss the sequence of infant feeding development and feeding skills using Table 5.6: Sequence of infant feeding development and feeding skills. Provide a similar overview of the nutrition requirements for children and adolescents. Table 5.7: Quantity and proportions of foods by age provides an overview of quantity by age.

Ask participants: What are some nutritious dishes or meals that you can recommend to your client to

help them meet their nutritional needs? Infants require high caloric intake that includes sufficient levels of carbohydrates and protein for growth and to activity. An infant’s ability to progress from liquid to solid food is dependent upon multiple factors including the development of oral motor feeding skills. Table 5.6 outlines the normal development of sucking, swallowing, biting, chewing, hand and body control, and how they affect the infant’s ability to consume liquids and solids. Texture, consistency, type and amount of food should complement the infant’s feeding skills and development of the gastrointestinal tract. Table 5.6: Sequence of infant feeding development and feeding skills Approximate Age

Mouth Patterns Hand Body Control

Feeding Skills

Birth through 5 Months

Sucking/swallowing reflex, tongue thrust, poor lip closure

Poor control of head, neck, trunk

Swallows liquids

6 months Draws in lower lip as spoon is removed from mouth, up and down movement, transfers food from front to back of tongue to swallow

Begins to sit alone, unsupported, good head control, uses whole hand to grasp objects

Takes in spoonfuls of thick porridge and swallows without choking, controls the position of food in the mouth

6-9 months Up and down munching movement, positions food between jaws for chewing

Begins to sit alone, unsupported, begins to use thumb and index finger to pick up objects

Begins to eat thick porridge and well mashed foods, eats from spoon easily

8-11 months Complete side-to-side Sits alone easily Begins to eat


tongue movement, begins to curve lips around lip of cup

ground or finely chopped food or mashed foods, begins to feed self with hands, drinks from cup

10-11 months Rotary chewing (grinding)

Begins to put spoon in mouth, begins to hold cup

Eats chopped food, small pieces of soft, cooked food

CHILD AND ADOLESCENT GROWTH

Calorie and nutrient needs of children from one year of age to adulthood varies considerably depending on physical activity, body size, gender and health. For example, as children get older, fewer servings of milk and dairy products are required, while more servings of the bread and grain products are needed. However, while the number of required servings and meals may be reduced, the absolute amount of food consumed is the same or greater, because serving and meal size increases as children get older. Table 5.7 illustrates the difference in serving sizes based on age. Children eat larger portions as they get older. The table can be used as a general guide for the quantity and proportions of foods needed daily. Fats, sauces, desserts and snack foods should be included as servings, as they provide additional energy. The table assumes that the reader is familiar with the many foods that comprise each food group. It is the responsibility of healthcare workers to provide caregivers with education and support around the need for variety in the diet. Children with HIV should be referred to nutrition programs if needed, and their caregivers educated on how to manage the symptoms of malnutrition in their children. These issues are more fully developed in Session 5.8. Table 5.7: Quantity and proportions of foods by age

Serving size1 Food Group

Servings per

day 1-3 Years

4-6 Years 7-12 Years 13 Years –

adult

Milk and dairy products

4-5 servings for 1-3 years

3 servings for 4 years thru adulthood

1/2 cup2 1/2-2/3 cup 1/2-1 cup 1 cup

Meat, fish, poultry or protein equivalent

2-3 servings

2-4 table-spoons2

2-4 tablespoons

4 tablespoons or 1/4 cup

4-6 tablespoons or 1/4 -1/3 cup


Fruits and vegetables

5-9 servings

30-60gm vegetables, or 1/2-1 small fruit, or 1/3-1/2 cup juice

30-60gm vegetables, or 1/2 to 1 small fruit, or 1/3-1/2 cup juice

1/4-1/2 cup vegetables, or 1 medium fruit, or 1/2 cup juice

1 cup vegetable, or 1 medium fruit, or 3/4 cup juice

Bread and grain products

3-4 for 1-6 years

4-5 for 7-12 years

6 plus for 13 thru adulthood

1/2-1 slice bread or 1/4-1/2 cup cooked cereal, rice or spaghetti

1 slice bread or 1/2 cup cooked cereal, rice, spaghetti

1 slice bread or 1/2-1 cup cooked cereal, rice, spaghetti

1 slice bread or 1 cup cooked cereal, rice, spaghetti

Notes 1 Amounts shown in this table are averages. The number of “servings” that a child needs

depends on age, health status and activity levels. A child with a chronic illness or a child who is very active will need more food than a healthy, sedentary child.

2 1 “cup” is approximately the size of a tea cup, 240 ml; 1 “tablespoon” is approximately 15 grams.

3 Adult protein portion is, for example, one egg, 1/3 cup nuts, or 1/2 cup cooked beans.

Examples of each food group Milk and dairy products: Milk, yogurt, amasi/maas, cheese Meat, fish, poultry or protein equivalent: chicken, beef, mutton, pilchards, offal

(tripe), peanut butter, eggs, beans, pulses (lentils) Fruits and vegetables: spinach, morogo, butternut, cabbage, apricots, peaches,

pawpaw, turnips, tomatoes, carrots, beets Bread and grain products: Bread, pap or phutu (mealie meal), sorghum

(lesheleshele and motoho), rice, samp, spaghetti, cereal Fats like oils, butter and margarine should be used sparingly. Slightly larger quantities can be used to help increase weight gain. Fatty foods like vetkoek (magwenya), samosas, chips and crisps should be eaten very rarely. Sugar, including sweets and cool drinks, and salt, including salty foods like crisps and biltong, should also be taken in very small quantities. Nutritious and affordable dishes include lentil stew, cowboys and crooks (samp and beans), and morogo, beans and phutu.

THE 24-HOUR RECALL


Introduce and facilitate Exercise 4. In Exercise 3, participants practised data


gathering for a 24-hour recall. Those skills are essential to obtaining an accurate report of food intake. In this exercise, participants will gain experience evaluating the sufficiency of an individual’s diet.

The 24-hour recall is an important tool to assess diet patterns and nutrient adequacy, particularly among caregivers who cannot complete diet logs. This method provides valuable insight into actual food intake, and with the inclusion of an evaluation portion, gives the healthcare worker specific guidance on how best to approach and supplement the child’s diet. The healthcare worker should use the evaluation portion of the 24-hour recall as a learning tool for the caregiver, recommending specific foods and portion sizes that are within the caregiver’s means. If it is not possible for the caregiver to produce, purchase or prepare the recommended foods, a referral to a food program should be made. (Session 5.7 covers counselling skills in more detail.)

Exercise 4: Evaluating Nutrition Adequacy Large group discussion: participants stay in large group

Purpose To provide experience evaluating the 24-hour recall collected during Exercise 3.

Duration 20 minutes

Introduction This exercise will provide participants with an opportunity to evaluate a 24-hour diet recall. During Exercise 3, participants collected dietary information. During this exercise participants will evaluate the diet and nutrient adequacy of a volunteer’s diet.

Activities Ask for a volunteer to share the 24-hour diet recall that was collected during Exercise 3.

Post the flipchart paper with the volunteer’s 24-hour recall. Post a blank flipchart paper next to the 24-hour diet recall. Create 5

columns and label them (this can be done in advance): 1. Milk and dairy 2. Meat, fish, poultry or protein equivalent 3. Fruit and vegetables 4. Bread and grain products 5. Fats and sweets

Proceed through the volunteer’s 24-hour diet recall and place a mark in each column for every portion from each food group.

Tally the total number of portions from each column. Compare the total number of servings in each food group to the

recommended daily portions (Table 5.7: Quantity and proportions of foods by age).

Debriefing Remind participants that they should establish whether the 24-hour recall represents the typical diet or whether it has been modified since the child was ill or for some other reason.

Encourage participants to think of nutritious and affordable dishes and meals they can recommend to their clients.

This exercise was presented to provide experience evaluating diet


adequacy. Give participants time to comment and ask questions about diet assessment. Emphasize that the recommended servings and portions each day can be used as a general guide for helping parents and children identify areas to improve their diet. Reinforce that servings should be increased for children living with HIV, particularly those who show insufficient weight gain.


SESSION 5.4 PREVENTION OF FOOD- AND WATER-BORNE ILLNESS

SESSION DURATION 30 minutes

SESSION LEARNING OBJECTIVE Describe the prevention of food- and water-borne illness.


Step 1: Review the learning objective for this session. Step 2: Describe the prevention of food-borne illness through food hygiene. Key Point: The key points for this session are:

People living with HIV are at higher risk of getting sick from food that has not been prepared or stored properly. It is important to work with families in a respectful way to improve their food storage and hygiene practices.

Find ways to include children in discussion of food, nutrition and food hygiene.

PREVENTING FOOD-BORNE ILLNESS


To encourage discussion, ask participants: What do you know about preventing food-borne illness? What symptoms of food-borne illness have you seen in your practice and how did

you advise caregivers? Ask a participant to demonstrate good hand-washing technique (for the home).

Sometimes, caregivers become offended if they think healthcare workers are implying that they are not clean. If participants have experienced this, discuss ways to make food sanitation a more comfortable topic for parents and caregivers.


Food-borne illnesses are diseases, usually either infectious or toxic, caused by agents that enter the body through the ingestion of food. Everyone is at risk of food-borne illness. People living with HIV are at higher risk of getting sick from food that has not been prepared or stored properly. In every household some knowledge about food-borne disease is essential. The first essential is a well-organised system for the safe disposal of human waste, such as a latrine. Babies’ nappies need to be cleaned/disposed of safely, away from areas where food is stored, prepared and eaten. Bacteria that cause disease multiply rapidly in many foods, particularly foods of animal origin that are warm and wet. If foods are not stored at low temperatures (below 5°C) millions of bacteria will breed in them. For example, meat stew will deteriorate very quickly, stiff maize porridge moderately quickly and bread less quickly. Uncooked dry rice granules will not deteriorate quickly and therefore can be stored without refrigeration for longer periods of time. Following are some basic recommendations for food safety. FOOD HYGIENE

Preparation Buy fresh food that looks clean and uncontaminated and has a good appearance. It

should not have a bad smell, mould or discoloration. If the food is canned, the can should not be bulging, dented or discoloured.

Always wash hands with clean running water and soap before preparing food and eating.

Do not thaw frozen food at room temperature; thaw in the refrigerator if available. Families without a refrigerator should avoid purchasing frozen food. Do not return thawed foods to the freezer.

Keep preparation area, dishes and utensils clean. Wash raw fruits and vegetables thoroughly before eating. Wash vegetables before cutting, cook immediately for a short time and eat

immediately to preserve nutrients.

Cooking Cook meat, fish, and eggs until well done to avoid food poisoning. Do not eat raw eggs since a raw egg may contain many dangerous bacteria. Cook

eggs until the whites are no longer clear; hard boiled eggs should boil for 10 minutes. Ideally, prepare fresh food for people living with HIV, do not store after cooking. If

food is stored, use a clean, covered container; store in a cool place. Consume any leftovers within two hours, unless refrigerated.

Do not eat food that has fallen on the floor.

Basic rules of hygiene Always teach children the basic rules of good personal hygiene — they should be taught to wash their hands after using the latrine and before touching food or eating. Teach children not to eat soil or dirt and to avoid putting objects and food that have fallen on the ground in their mouths.


Storage Cover food to prevent contamination from flies and dust. Dry foods such as cereal

grains and flours or legume seeds should be left in a cool dry place in containers that prevent rodents and other pests from gaining access to them.

Store food in a cool place. Many foods are best stored in a refrigerator. If the family has a refrigerator, recommend refrigerating all cooked and perishable foods (including meat and milk products), below 5 °C; do not store food too long, even in a refrigerator.

KEEPING THE KITCHEN CLEAN Keep rubbish in a covered bin (and empty it regularly) so it will not cause offensive

smells and attract flies, which can contaminate food with germs. Store kitchen utensils on a raised platform — where there is sunlight and enough air

circulation — rather than on the ground where they can be contaminated. Keep dish towels and hand towel separately. Use dish towels for wiping dishes only;

use the hand towel to wipe hands after washing. Dish towels should be washed and boiled often to kill germs.

If the family has a refrigerator, they should defrost and clean it thoroughly. Refrigerators should be cleaned inside and out once or twice per week. Baking soda helps to eliminate odours; two tablespoons can be mixed with one litre of warm water to clean the refrigerator. If the freezer has a half centimetre of thick frost then it should be defrosted.

PREVENTING WATER-BORNE ILLNESS


To encourage discussion, ask participants: How do you help caregivers to make sure that the water their children drink is safe?

SAFE WATER Children and families have many fewer illnesses when they have access to safe, clean water and when that water is stored properly in the home. Safe water sources include piped systems, tube wells and wells and springs that are protected. Water from other sources, like ponds, lakes, streams, open tanks and step wells needs to be treated so it can be safe. There are a number of options for treating water: Boiling: Boil water until big bubbles rise to the surface — also referred to as a

rolling boil — for one to two seconds. This technique kills germs, but the fuel costs may be high. If it is not possible to boil drinking water all the time, encourage caregivers to boil water for their children all the time and for themselves when they are sick.

Chlorination: Disinfect water with a specially packaged chlorine solution or tablet or non-perfumed Jik solution. Mix one teaspoon of Jik into 25 litres of water; wait at least two hours—and preferably 24 hours—before use.


Solar disinfection: Disinfect water using the solar water disinfection method (also called SODIS). Put water in a clean, clear plastic container (up to three litres in volume). Fill the plastic bottle about three quarters full with water. Shake the bottle vigorously twenty times to dissolve air into the water. Fill the plastic bottle and replace the cap. Put the plastic bottle in direct sun for at least six hours. If possible, rest the bottle on a reflective surface such as the roof of the house, metal, light coloured rock or tin foil. If the weather is cloudy, leave the bottle outdoors in the sun for two full days.

Filter: If water filters are available, they can be used to remove some microbes and sediment. As filters do not disinfect water, water must be boiled or disinfected using another method before pouring into the filter. Ceramic filters with small pores are effective but they need to be cleaned monthly.

Other: Powders or tablets like Chlor-Floc settle unclear water and disinfect. Follow instructions on the package carefully.

Information on sterilising water for use in infant formula is provided in Module 4. Teach children and caregivers to keep their water supply safe. Keep wells covered and use a hand pump if possible. Dump human waste, waste water, and other dirty water away from the water source. Build latrines at least 15 metres and downhill from the water source. Keep buckets used to collect water clean. Keep animals away from water sources. Do not use any chemicals near the water source.

Teach children and caregivers to keep their home water supply safe Where water is stored at home is just as important as the water source. Often, clean

water is contaminated because it is not stored the right way. Store water in a clean container. If possible use a container

with a narrow opening or a tap/spigot. Always keep the container covered. Do not dip hands into the water container. Instead, use a

clean cup to get water and transfer it to another cup. Do not drink from the cup and then put it back in the water

container. Keep animals and small children away from the water

container. Note: See Resource list at the end of this module for additional materials, including materials to help teach children and families about living positively with HIV.

SODIS works best if using number 1 plastic PETE bottles. The bottle should be as clear and clean as possible:

bottles that are scratched will not work as well.


SESSION 5.5 NUTRITION-RELATED SIDE EFFECTS OF ARV THERAPY

SESSION DURATION 30 minutes

SESSION LEARNING OBJECTIVE Describe common nutrition-related side effects of ARVs. Discuss traditional healers and traditional remedies in the context

of HIV.


Step 1: Review the learning objectives for this session. Step 2: Provide an overview of side effects of ARVs used in the first and

second line regimens as well as cotrimoxazole. Note that it is important to address side effects as side effects can determine adherence.

Step 3: Discuss traditional healers and remedies. Key Points: The key points for this session are:

Parents and caregivers should be educated about the side effects of ARVs, particularly as they can affect adherence.

Traditional healers play an important role in South Africa’s response to HIV — they can provide support, encourage practices that reduce transmission and stigma, and support adherence to ARV therapy regimens.

Because most traditional therapies have not been subjected to structured formal research, it is important that they are avoided or, at least discussed with a healthcare worker for any known interactions with ARVs.


SIDE EFFECTS OF ARVS


To encourage discussion, ask participants: What kind of side effects have you seen your paediatric patients experience?

“Which drug was the side effect related to? When you discuss the content in Table 5:8 focus on the ARVs prescribed in local

clinics as first line therapy, as well as cotrimoxazole. There is no need to cover the other drugs, unless you have clients on second line therapy. Read out the name of the medication and then ask if anyone knows how to take it (for example with or without food). Then ask if anyone knows the potential gastrointestinal (GI) side effects. Then, finally, ask if anyone is aware of any serious side effects, for which the client might need to be hospitalised or the medication stopped.

In this session, some of the nutrition-related side effects of ARVs used in the current first and second line regimens are presented. In the next session, the management of the more common nutrition-related symptoms, including ARV side effects, are discussed. It is important that healthcare workers, parents and caregivers are aware of the side effects of the ARVs and know how medications should be taken to reduce the probability of these side effects. The most common side effects occur during the first 6 or so weeks of therapy and subside soon thereafter. Side effects of ARVs can affect adherence. As adherence to ARV therapy is critical to improving and maintaining continued good health, it is important that healthcare workers treat side effects quickly when they occur. A list of common nutrition-related side effects of ARVs in the first and second line regimens is listed in Table 5:8 below. Table 5:8: Potential side effects of ARVs and CTX Name How to take it GI and nutrition side effects

First line regimen

Stavudine (d4t)

With or without food. Store oral suspension in refrigerator.

During early weeks: loss of appetite, nausea, vomiting, diarrhoea, constipation, abdominal pain and dehydration.

Lamivudine (3TC)

With or without food.

Well tolerated, few side effects. During early weeks: nausea which generally subsides over time Other side effects can include: decreased appetite, diarrhoea, abdominal pain, anaemia


Lopinavir (LPV)

With or without food. Avoid St John's wort.

Diarrhoea (most common in first 2 months) and nausea. Stomach pain and vomiting are less common side effects

Ritonavir (r)

With meals if possible. Avoid St John's wort.

During early weeks: nausea, vomiting, diarrhoea, and tingling or numbness around the mouth.

Efavirenz (EFV)

With or without food, but do not take with a high fat meal. Take at bedtime.

Less common side-effects include dry mouth and changes to taste.

Second line regimen

Zidovudine (AZT)

With or without food, however, risk of nausea may be less if taken with food

During early weeks: fatigue, nausea, vomiting, and altered taste.

Didanosine (ddI)

With water only, 30 minutes before or 2 hours after eating. Do not take with juice, milk or antacid.

Less common side-effects include nausea, vomiting, and dry mouth. Many of these are mild and only occur in the first few weeks of treatment.

Nevirapine (NVP)

With or without food. Avoid St John's wort.

Most people experience very few or no side effects. The most common side-effects are nausea, vomiting, diarrhoea and abdominal pain.

For Efavirenz and Lopinivir/ritonavir, see first line regimen drugs, above.

Other drugs

Cotrimoxazole (CTX)

Take with food and plenty of water. Drink water frequently throughout day.

Nausea

Many ARVs and other drugs cannot be taken with alcohol; educate caregivers to never give alcoholic beverages — not even traditional alcoholic drinks — to children who are taking any medication.


TRADITIONAL HEALERS AND REMEDIES


To encourage participation, ask participants: Do you ask about your client’s use of traditional healers? Why or why not?

TRADITIONAL HEALERS As the primary healthcare provider for many South Africans, traditional healers play an important role in South Africa’s national response to HIV. Nationwide efforts to train traditional healers on HIV have enabled them to effectively counsel their clients on HIV prevention and care. Traditional healers possess invaluable cultural knowledge, serve as respected leaders in their local communities, and can sometimes be effective in addressing community based stigma and discrimination. However, because most traditional healers work independently from the national healthcare system, they are only loosely regulated, if at all. Furthermore, natural plant remedies recommended by traditional healers could potentially interact with ARVs. TRADITIONAL REMEDIES Most traditional herb therapies taken for HIV-related disease and symptoms have not been subjected to structured formal research. Therefore their effect on the course of HIV disease, potential toxicities and possible interaction with ARVs is unknown. In many cultures, traditional plant-based treatments for common illnesses, such as for fevers or colds, are the norm. It is important that healthcare workers ask caregivers about any alternate sources of treatment, whether prescribed by a traditional healer or whether a family remedy that they themselves have prepared. A non-judgemental attitude on the part of the healthcare worker will encourage openness and honesty from the caregivers about what other treatments they may be using. Healthcare workers should also enquire about dosage, preparation and administration. These treatments, while they may be a part of the culture and handed down from one generation to the next, may have the potential to cause harm, particularly among children with HIV. Where traditional remedies are not or cannot be avoided, the following are recommendations for clients: Be aware that traditional plant remedies, like other medicines, can cause side effects.

These side effects can vary depending on the time of year, amount of rainfall recently and preparation (such as heating).

Ensure that all components of traditional remedies (particularly plants, animal products, and water) have been cleaned and sterilised (usually by boiling) before use.

Be aware of possible health risks. While traditional medicine has been effective in treating and preventing some illnesses, traditional remedies can also pose health risks.

Ensure that you inform your healthcare worker of any traditional medicines or herbs that you have been exposed to or are taking.

Discuss with your healthcare worker any possible traditional plant remedy-ARV drug interactions.


SESSION 5.6 MANAGEMENT OF NUTRITION-RELATED SYMPTOMS


SESSION LEARNING OBJECTIVE Describe the management of common nutrition-related symptoms.


Step 1: Review the learning objective for this session. Step 2: Facilitate Exercise 5: Symptom Management Discussion. Participants

will discuss the management of key nutrition-related symptoms common in HIV infection, including diarrhoea, poor appetite, nausea and vomiting, sore mouth and finally anaemia. Allow participants to share what they know and fill in with the session content as needed.

Step 3: Present the preparation of oral rehydration solution. Step 4: Summarise the exercise discussion and present additional information

not covered in the exercise. Key Point: The key point for this session is:

Many common nutrition-related symptoms can be managed through food-based interventions.


Facilitate Exercise 5: Symptom Management Discussion.

Exercise 5: Symptom Management Discussion Small group work

Purpose To provide participants with an opportunity to describe the ways that HIV symptoms are treated with nutrition intervention (in addition to ARV therapy).

Duration 40 minutes

Introduction This exercise will provide participants with an opportunity to share their expertise on the nutritional management of HIV symptoms.


Activities Post 4 flip charts in the front of the room. Label the flip charts: 1. Diarrhoea 2. Loss of Appetite 3. Nausea and Vomiting 4. Sore Mouth

Break participants into four groups and assign one symptom to each group.

Ask participants to spend 20 minutes discussing in their small group: Their experience with nutrition treatment for the symptom Remedies or coping strategies When to tell the client to return to the clinic for treatment of

severe symptoms Have them record answers on a flip chart. After 20 minutes, bring the groups together and have each group

present their symptom management lists. Allow other groups to add. Fill in with content from this session as needed.

Debriefing This exercise was presented to provide the opportunity to share experience with nutrition management of symptoms.

Give participants time to comment, share experiences and ask questions.

Correct any misconceptions and supplement information that was not mentioned during the discussion.

NUTRITION MANAGEMENT OF HIV AND AIDS-RELATED SYMPTOMS


Use the information below to supplement the discussion in Exercise 5: Symptom Management Discussion.

Present the information in Table 5.9: Preparation of ORS Children and adults with HIV have to learn to manage a number of symptoms that are a result of their HIV infection or an HIV-related infection, or even a side-effect of medication. Many of these symptoms — such as diarrhoea, poor appetite, nausea and vomiting and pain when eating — can be addressed through nutrition-related interventions. Healthcare workers will be called upon to treat these symptoms as well as anaemia, and hence should be familiar with their management.


DIARRHOEA

Educate client to come to the clinic if…

HCW should refer to hospital if…

Dehydration is the most important complication of persistent diarrhoea. Educate the caregiver to bring the child for evaluation if: Vomiting and diarrhoea are both

present. Diarrhoea alone (defined as passing

watery stool three or more times a day) persists for more than three days

There are physical signs of dehydration, e.g., dry lips and mouth membranes, sunken eyes and fontanel (soft spot on baby’s head), decreased urination and rapid breathing or pulse.

Fever develops Blood appears in the stool The child becomes very weak

The following groups of children should be managed in the hospital: Infants less than two weeks of age Malnourished children

Children with other danger signs, such as: Convulsions Altered level of consciousness Persistent vomiting Respiratory distress Persistent diarrhoea with dehydration Hypothermia Surgical abdomen Dysentery in child <12 months

These children should not be managed at primary health care establishments, but should be referred. Give pre-referral treatment: first dose of antibiotic (IM Cefriaxone) and start rehydration.

Diarrhoea may be experienced with the following ARVs: stavudine, lamivudine, lopinavir/ritonavir and nevirapine. Usually, diarrhoea associated with these medications is mild and short-lived. Investigate other causes if severe or prolonged; if other causes cannot be established, referral to an HIV specialist is recommended. See SA Guidelines for Management of HIV-infected children (2008). Diarrhoea is one of the leading causes of death among children in sub-Saharan Africa, accounting for approximately 20% of all illness-related deaths among the under-5 population. Diarrhoea is particularly serious for children living with HIV as it leads to the loss of water and vital minerals from the body. This loss, made worse if the child is also vomiting, makes the child weak and increases the chance that she or he will get sicker. In children with no visible signs of dehydration, the goal is to prevent dehydration. If child is breastfeeding, encourage more frequent and longer feeding and give sugar salt solution (SSS) between feeds. (SSS: 1 litre of clean or boiled water + 8 level teaspoons of sugar + ½ teaspoon of salt.) Interventions for mild dehydration: Give oral rehydration solution 80 ml/kg over 4 hours (Table 5.9). Increase the

amount if the child wants more. Encourage the mother to give the ORS by cup or spoon Encourage the mother to continue breastfeeding, where applicable. Provide zinc supplementation — Age 0 to 6 months: 10 mgs daily for 2 weeks; Age 6

months or older 20 mgs daily for 2 weeks. If child vomits, wait for 10 minutes, warm the ORS slightly and resume rehydration.


Reassess after four hours: if unchanged, continue. If signs have disappeared, follow recommendations above for children with no visible signs of dehydration. If child is worse, hospital management is required. Give pre-referral treatment: First dose of antibiotic (IM Cefriaxone) and continue rehydration.

Table 5.9: Preparation of ORS Preparation of oral rehydration solution (ORS) for dehydration: Use clean, boiled water. From a packet: Follow directions on the packet. With salt and sugar: To one full litre of water, add one-half teaspoon of salt and eight

teaspoons of sugar. Stir or shake well. The water should taste no more salty than tears.

With powdered cereals: To one litre of water, add one-half teaspoon of salt and eight teaspoons of powdered cereal. Rice is best, but fine ground wheat flour, maize, sorghum or cooked mashed potatoes can also be used. Boil for five to seven minutes to make a liquid soup or watery porridge. Cool the drink quickly.

The following tips provide guidance for the treatment of children with diarrhoea (without dehydration) managed at home: LIQUIDS If the child is breastfed, increase frequency of exclusive breastfeeding; if the child is

formula fed, increase frequency of exclusive cup feeding. Drink plenty of water and other fluids to replace water lost. See the fluid guidelines

in Table 5.10: Normal fluid guidelines for daily fluid recommendations. Children up to two years should drink ¼ to ½ cup (50-100ml) after each loose stool, children two years or more should drink ½ to one cup (100-200ml) after each loose stool.

Drink soups, fruit juice with water or an oral rehydration solution; avoid sweetened juices and fizzy drinks.

Temporarily eliminate milk. Alternatives include fermented dairy products such as yoghurt with live culture and amasi/maas/madila (sour milk product). When the child is ready to begin drinking milk again, recommend starting with small amounts and progressing to larger quantities as the child tolerates it.

FOODS Do not stop eating. Eat smaller meals more often. Eat soft, mashed, moist foods such as soft vegetables and fruit, porridge, rice,

bananas, mangoes, pawpaw, watermelon, potatoes and stews. Soft vegetables such as squash, pumpkins, carrots, and vegetable soup are also recommended.

Eat refined foods such as white rice, maize meal, white bread, spaghetti and potatoes.


Vegetables and fruit should be peeled and cooked so they are better tolerated by the child.

Temporarily remove foods high in insoluble fibre (roughage) from the diet (e.g., raw vegetables and fruit skins, dried fruit, wholemeal/dark bread, whole-grain cereals, oats, nuts, seeds and pulses/legumes such as beans, lentils and chickpeas).

If fatty food causes problems, lower the amount of fat by using less cooking oil, cutting fat or skin from meat and boiling food rather than frying it. Fat is an important food source and should not be avoided unless necessary.

Avoid foods that make diarrhoea worse, such as spicy foods and unripe or acidic fruits (e.g., oranges).

Table 5.10: Normal fluid guidelines Children should drink water and fluids as often as possible throughout the day and night and every time a stool is passed. Children between 1-10 kg require 100 ml*/kg/day Children between 10-20 kg require 1000ml plus 50ml for each kg over 10kg Children 20-30 kg require 1500ml plus 20ml** for each kg over 20kg Children > 30kg require 35ml/kg/day

In severe cases of diarrhoea, water and fluid will need to be further increased. * 100ml is just less than a half of a tea cup. ** 20ml is just more than a tablespoon (not a teaspoon, but

rather the larger spoon, which is referred to as a tablespoon)

POOR APPETITE



Swallowing is difficult Losing weight Accompanied by vomiting more than

four to five times in a day Loss of appetite continues despite

trying the suggestions below

Loss of appetite is accompanied by another condition requiring hospitalisation

Poor appetite is a common side effect the ARVs lamivudine and nevirapine. This effect is usually mild and short-lived. Investigate other causes if severe or prolonged; if other causes cannot be established, referral to an HIV specialist is recommended. See SA Guidelines for Management of HIV-infected children (2008). Poor appetite is a common problem for those living with HIV. It can have many causes including infections, pain (particularly in the mouth or stomach), depression or tiredness. The feeling of hunger may disappear or the child may be easily full and therefore not want to eat enough. It is very important to encourage children to continue eating to prevent weight plateau, loss and malnutrition and to maintain strength.


Following are tips that may help the child with poor appetite. Even if a child is not hungry, encourage eating. The best way to regain appetite is to

eat. Try different foods until the child eats; encourage a mixed diet. If financially possible, give the child some of their favourite foods until their appetite

improves. Eat smaller meals more often. The child should eat whenever her or his appetite is

good — parents should try not to be too rigid about fixed times for meals. Add flavour to food and make it look and taste interesting. Drink a lot of water, milk, yoghurt, soups or juices throughout the day, primarily

after and in between meals. Drinking with meals can cause early feeling of fullness and limit appropriate food intake.

Show the child how to rinse her or his mouth before eating — this can make food taste fresher.

Avoid foods with very strong smells which can put them off from wanting to eat. Try to engage the child in light exercise activity, such as walking outdoors, before

each meal as a way to stimulate appetite. Children should eat with family or friends. If the child has to stay in bed, the family

can join him or her at the bedside.

NAUSEA AND VOMITING



Dehydration is the most important complication of persistent vomiting. You should be concerned if: Vomiting is accompanied by a fever

over 38.3 °C. Vomiting and diarrhoea are both

present. Vomiting alone persists for more than

12 hours in children under six years or 24 hours in older children.

There are physical signs of dehydration, e.g., dry lips and mouth membranes, sunken eyes and fontanel (soft spot on baby’s head), decreased urination and rapid breathing or pulse.

Dehydration is severe (see “Diarrhoea” above).

You suspect that vomiting is a sign of a more serious illness (appendicitis, blocked intestine, meningitis, severe gastroenteritis, etc).

Nausea and vomiting are associated with unexplained pain, fever, vomiting blood, or having bloody or black, tarry bowel movements.

Nausea and/or vomiting can be side effects of most of the ARVs including: stavudine, lamivudine, lopinavir/ritonavir, zidovudine, didanosine, nevirapine; co-trimoxazole can also cause nausea. Generally, these effects are mild and short lived. Investigate other causes if severe or prolonged; if other causes cannot be established, referral to an HIV specialist is recommended. See SA Guidelines for Management of HIV-infected children (2008). Nausea reduces the feeling of hunger and can be caused by certain foods, hunger itself, illness, stress and lack of water. As mentioned previously, vomiting results in the loss of vital minerals from a child’s body, therefore every effort should be made to supplement the child’s diet if she or he has been vomiting.


The following tips provide guidelines for treating children who experience nausea and vomiting: If the child is breastfed, increase frequency of exclusive breastfeeding; if the child is

formula fed, increase frequency of exclusive cup feeding. Sit up when eating and remain upright for one or two hours after eating. Drink plenty of fluids after meals. Stay in another room during food preparation. The smell of preparing or cooking

food may worsen the feeling of nausea. Foods to eat and drink: If a child is vomiting, drink small amounts

of water, soups and teas. Smell fresh orange or lemon peel, or place

some lemon juice in hot water and drink. Drink ginger tea to relieve nausea. Eat soft, bland, simple boiled foods, such

as porridge, potatoes and beans. The child can go back to solid foods when the vomiting stops.

Eat dry and salty foods such as toast, rusks, crackers and cereal. Foods to avoid: Those that have a strong aroma Fatty, greasy, and very sweet foods that can make nausea worse A parent should try to remove one food at a time from the child’s diet to determine

if a particular food is causing the nausea/vomiting.

SORE MOUTH OR THROAT PAIN WHEN EATING



You cannot eat for more than a day despite trying the suggestions below.

Sore mouth/pain when eating is accompanied by another condition requiring hospitalisation.

Sore mouth/pain is more likely to be a symptom of an HIV-related condition than a side effect of an ARV. Soreness of the mouth and tongue is common in people with HIV and often makes eating difficult. Following are some tips to help infants, children and adolescents who experience pain when eating. Food and drink If the child is breastfed, increase frequency of exclusive breastfeeding; if the child is

formula fed, increase frequency of exclusive cup feeding. Give paracetamol half an hour before solid feeds. Try a topical anaesthetic (Teejel or Bonjela).

Recipe for ginger tea Add 1/2 teaspoon chopped fresh ginger to one cup boiling water. Boil slowly for ten minutes. (Optional: add 1/4 teaspoon ground cinnamon.) Cover and allow to stand for five minutes. Strain.


Eat soft, thick, mashed, smooth, or moist (non-acidic) foods such as mashed carrot, avocados, squash, pumpkins, pawpaw, bananas, yoghurt, creamed vegetables, soups/porridge, spaghetti, and minced food.

Add liquids to foods or soften dry food by dipping in liquids. Offer foods at room temperature or cooler. A child should try drinking cold drinks,

soups, vegetable, fruit juices, even ice cream, ice lollies or ice cubes where available. Drink water or yoghurt or amasi/maas/madila (sour milk product). Use a straw for drinking fluids.

Avoid the following foods and drinks: Citrus fruits, acidic or sour foods, such as orange, grapefruit, pineapple, tomato,

lemon, and vinegar Very sweet foods Very spicy and salty foods such as chillies and curries Food and drinks that are too hot or too cold Foods that need a lot of chewing such as raw vegetables, or are sticky and hard to

swallow such as peanut butter If candida (oral thrush) is diagnosed, treatment with an antifungal medication may be required. Oral care Clean the child’s mouth at least twice a day (morning and evening, and — when

possible — after meals) with cotton wool dipped in mildly salty warm water or a clean cloth and cinnamon water. Cleaning the mouth can prevent infection and promote healing.

If the child’s gums are painful and the child cannot brush her or his teeth, rinse the child’s mouth with 1 teaspoon bicarbonate of soda mixed with a glass of warm boiled water.

The child should chew a small piece of green mango, kiwi or green pawpaw, which may help to relieve pain and discomfort.

ANAEMIA


To encourage discussion, ask participants: What are the symptoms of anaemia? What do you do when you see a child that you think is anaemic? How do you educate caregivers to bring possibly anaemic children into the clinic

sooner?



Skin colour seems unusually pale, particularly in the nails and lips

Feeling tired, weak or low-energy. This fatigue may make the child more

Anaemia plus bruising or purpura, hepatosplenomegaly, bone tenderness or jaundice

Signs of cardiac failure OR


irritable or fussy than usual Feeling dizzy or lightheaded Having headaches Having cold hands and feet Experiencing rapid or irregular

heartbeat

Cardiac flow murmur

Anaemia can be a side effect seen with the ARVs lamivudine, zidovudine and cotrimoxazole, but is common only with zidovudine. Anaemia can be treated and zidovudine can be continued with mild to moderate anaemia (Grades 1 and 2 as defined in the SA Guidelines for Management of HIV-infected children, 2008). For Grade 3, treatment is initiated and the test repeated in 1 week. If no improvement, or if anaemia worsens, all ARV treatment should be stopped and the child referred for specialist care before re-starting ARVs. Anaemia is common in HIV-negative and HIV-infected children and may be due to acute illnesses (such as malaria, hookworm or whipworm), nutritional deficiency, poor dietary absorption of essential minerals, congenital causes (such as sickle cell anaemia, thallassaemia). In HIV-infected children it may also be due to opportunistic infections, drugs or the direct effect of HIV on the bone marrow or other body systems. Treatment of anaemia should be based on clinic protocol as shown in the algorithm in Figure 5.12. Figure 5.12: Management of anaemia


SESSION 5.7 NUTRITION COUNSELLING AND REFERRALS

SESSION DURATION 90 minutes (1.5 hours)

SESSION LEARNING OBJECTIVES Practise conducting nutrition counselling. Develop a preliminary referral network for nutrition-related

services.


Step 1: Review the learning objectives for this session. Point out that the skills covered in this session are applicable to many kinds of counselling and referral, not just nutrition-related.

Step 2: Recap critical elements of counselling. Participants will have an opportunity to practise these skills in Exercise 6: Nutrition management and counselling exercise.

Step 3: Quickly review the referral process. Then facilitate Exercise 7: Developing a Network for Nutrition-Related Referrals.


Nutrition counselling is communication with clients that provides an opportunity to gather information about the child’s problems and circumstances, praise practices that are healthy, offer information and make recommendations.

Because it is not possible for one organisation to provide the wide range of services needed by families, it is essential that healthcare workers are familiar with the local organisations that provide complementary services. It is also important that healthcare workers can refer clients to these services.

NUTRITION COUNSELLING


To encourage discussion, ask participants: Imagine what it would be like if a healthcare worker told you that your child is not

growing and that you must not be taking good care of the child. How would you feel?


How would you feel towards the healthcare worker? What would you do? Why do you think our clients do not always follow our recommendation? How can we increase the likelihood that our clients will make nutrition-related

behaviour changes? INFLUENCES ON A FAMILY’S ABILITY TO CHANGE Nutrition counselling is often referred to as the art of nutrition care because communicating with people is not an exact science. There are many issues, such as finances, tradition, access to transportation, and personal preference that may influence a family’s ability to make changes. In addition, the environment and culture, particularly the openness of the community to persons living with HIV, will have an impact on the acceptance of health care recommendations. Besides those previously mentioned, other factors may limit the ability of a caregiver and family to make nutrition-related behaviour change. These include: Location of clinic Health of the parent or caregiver Caregivers’ employment status Who controls the household money and time Number of other children in the home Other people’s beliefs, opinions and needs Whether the person has disclosed HIV status Stigma over inability to provide for one’s children Stigma related to feeding choices; for example, choosing to use infant formula could

result in neighbours suspecting or labelling the mother and children as HIV-positive Other risks, including stigma and potential discrimination, associated with the

recommended behaviour change FOUNDATION FOR NUTRITION COUNSELLING Nutrition counselling involves educating and making recommendations to prevent (further) growth faltering. Recommendations are centred on the needs of the child; these needs will change as the child develops. As the child matures, the relationship between healthcare worker and caregiver may broaden to encompass input from the child. Therefore, establishing an environment of openness and trust will be important to the continuing well-being and health of the child. Many people cannot do what they want to do or what a healthcare worker suggests they do. When conducting nutrition counselling, therefore, the healthcare worker must assess what the family/caregiver can reasonably be expected to accomplish. Nutrition counselling includes: Gathering information about the child’s current eating and activity patterns and

nutrition-related symptoms. Praising practices you want to encourage. Offering information. Suggesting changes for the family’s consideration.



Facilitate Exercise 6.

Exercise 6: Nutrition Management and Counselling Exercise Small group work: participants break into groups of three

Purpose To practise counselling a caregiver about a child’s growth problem

Duration 45 minutes

Introduction This exercise will provide participants with an opportunity to practise nutrition management and counselling.

Activities Ask participants to break into groups of three. One should take the role of “caregiver,” another, the role of “healthcare worker” and the third person the role of “observer.”

Ask participants to quickly review the growth charts in the Road to Health booklet (Appendices 2 and 3). Refer “observers” to the communication skills checklist in Appendix 6.

Explain that the scenarios follow the story of Sibongile. The first group will meet Sibongile when she is eight months old. The other groups will meet her at later ages.

Assign one of the following scenarios to each group; the scenarios may be used by more than one group if there is a large number of participants. 1. Scenario 1: Sibongile is eight months old. Her mother, Judith,

has weaned the baby from the breast and wants to learn about foods to introduce to her baby and about a breast-milk substitute (infant formula or cow’s milk, if available and affordable). She has been trying to feed the baby chopped table food, but the baby spits it out. Talk to Judith about introducing solids and the feeding skills she should expect her baby to have at eight months. Also, counsel the mother on feeding a breast-milk substitute until the baby is at least 12 months old. (Participants can refer to Table 5.6: Sequence of infant feeding development and feeding skills.)

2. Scenario 2: Sibongile is 10 months old. The baby has been going to bed at night without dinner because Judith is HIV-infected, recently symptomatic, and too tired in the evening to prepare dinner for herself or her baby. Speak with the mother about ways to seek support from friends and family, how to prepare meals in advance when she is feeling well (assume she has a freezer), and other ways to ensure she and her baby eat better.

3. Scenario 3: Sibongile is 12 months old and now weighs six kg (the group will need to plot baby’s weight). The baby has chronic diarrhoea. What would you counsel the mother?

4. Scenario 4: Sibongile is now 18 months old and weighs 7.8 kg (the group will need to plot baby’s weight) and Judith reports that the child has been suffering from nausea and vomiting for a day or so. Counsel with the mother about managing the nausea


and vomiting. 5. Scenario 5: Sibongile is now three years old and weighs 13 kg.

Child has acute diarrhoea. The child is on ARVs and does not have an opportunistic infection. What may be causing the diarrhoea? [hint: think toileting]. Speak with the mother about treating diarrhoea, preventing diarrhoea and about feeding a toddler.

Ask the “caregiver” and “healthcare worker” to role play the counselling session. The “observer” should watch and listen carefully, noting communication skills illustrated by the “healthcare worker” on her or his checklist.

If at any point the role play slows down, the “observer” can swap roles with either the “caregiver” or “healthcare worker.”

After about 15 minutes ask the groups to conclude their counselling sessions. Within the small groups, the observer should give the healthcare worker feedback using the checklist that she or he completed during the role play.

Ask the small groups to re-convene as a large group. Take 20 minutes to discuss the following questions: 1. What important points did the “healthcare worker” find out about the

“caregiver”? Which good counselling skills did the “healthcare worker” use? Caregivers: do you think the “caregiver” will follow the “healthcare worker’s” advice? Observers, do you think the “caregiver” will take the “healthcare worker’s” advice?

2. What was it like being the “healthcare worker?” 3. What was it like being the “caregiver?” 4. Healthcare workers: What questions did you ask? Which questions did you

wish you had asked? 5. Caregivers: What did you think of the “healthcare worker’s” questions?

Should any of the questions have been re-worded? Did the counsellor miss anything?

6. What observations did the “observers” make?

Debriefing This exercise was presented to provide participants with experience counselling a mother about nutrition and growth problems. Allow participants time to comment and ask questions. Correct any misconceptions and fill in any information that was left out.

NUTRITION-RELATED REFERRAL


To encourage discussion, ask participants: What is an example of a possible nutrition-related service? How do you know when to refer a client? Do you and other healthcare workers know where to refer clients for nutrition-

related services not offered in your clinic? Can you describe a positive referral relationship between your facility and another

organisation, related to nutrition?


Referrals may be made for children, caregivers or family members under the following circumstances: Client, caregiver or family member has unmet needs Unavailability or inaccessibility of services at the local clinic Client, caregiver or family request

Nutrition-related referrals can include referral to advanced care for malnutrition, for supplemental feeding, food relief, food baskets, community gardening, microcredit, animal husbandry, and so forth. Healthcare workers should be aware that all children who are at or below the – 2 line on the growth chart are considered to be in a “dangerous” zone; these children may be ill and need extra care. Children at or below the – 3 line on the growth chart are eligible for food supplements such as Philani fortified porridge (part of the protein energy malnutrition, or PEM, scheme). In addition, infant formula (e.g. Nan Pelargon) is provided for children living with HIV who are 0-6 months old through the PMTCT programme. Processes should be in place at each clinic to ensure proper provision or referrals for these services. Questions that may be asked if the healthcare worker is unsure of the need for a nutrition-related referral, — as per IMCI guidelines (see Nutrition Risk Score Card in Appendix 7). For all children: How is the child’s appetite? Do you have any difficulties getting the child to eat? Does the child have any problems with nausea, vomiting, diarrhoea, pain in the

mouth or when eating? Infants still breastfeeding or on formula: First ensure that the caregiver is not mixed feeding, that is, giving both breast milk

and formula. Mothers who breastfeed should do so exclusively in the first six months of life.

Is the child getting enough breast milk or formula? Ask how often the child breastfeeds and for how long on each breast.

If the mother is still breastfeeding, ask if she is getting enough food. Consider providing supplement food for the mother to increase the nutrients in breast milk.

If using formula, what are the barriers to getting enough formula for the baby? If using formula, ask about preparation method, availability of clean water, whether

caregiver is sterilising feeding equipment, and if the infant is bottle or cup fed. Older children: Are you able to give the child meat/milk/other protein-rich food every day? Is the child eating vegetables/fruit every day? Do you think the child is getting enough food? What are the barriers to the child getting enough food (e.g., money, transport, too

many children in the family)? Are you able to prepare foods for your child?


Based on the responses to these questions, and on the ability of the local clinic to provide the needed services and supplies, the healthcare worker should determine whether a referral is needed (see following section for steps in the process). If a referral is made for nutrition assistance, remind the caregiver that the supplemental food (e.g., infant fortified maize meal) is to be used in addition to the regular foods for the child, not as a replacement.


Facilitate Exercise 7.

Exercise 7: Developing a Network for Nutrition-Related Referrals Small group work: participants break into groups of three

Purpose To brainstorm a list of resources for nutrition-related referrals

Duration 15 minutes

Introduction This exercise will provide participants with an opportunity develop a list of local referrals for nutrition resources.

Activities Ask participants to break into groups of three, preferably all from the same facility or area (neighbourhood, location, village, etc.).

Ask participants to brainstorm for 10 minutes and fill in the Community Resource Worksheet (Table 5.11) with nutrition-related resources in their area. They do not need to complete all the information in every row or column.

Debriefing This exercise was presented to provide participants with an opportunity to brainstorm about nutrition-related resources in their area.

Emphasize that many different services can be included as nutritional referrals, including interventions for severe malnutrition; food banks or other places to obtain food supplements or food baskets; community garden projects; cookery lessons; microfinance, etc.

Let participants know that they may copy down additional resources during the breaks.

Remind participants that the referral worksheet can be used for any kind of referral, not only nutrition-related referrals.

Table 5.11: Community resource worksheet Type of organisation

Contact information Notes

Nutritional Support

Name of agency: Contact person: Address: Telephone number: Fees: Hours:


Material Support — clothing, school uniforms


Income-generating activity groups/support


HIV counselling and testing


Support group(s) or club(s)


Community- and faith-based organisations


Legal support Name of agency: Contact person: Address: Telephone number: Fees: Hours:

HIV care and treatment for children


HIV care and treatment for adults (caregivers or family members)



Support for OVC


Other Name of agency: Contact person: Address: Telephone number: Fees: Hours:


SESSION 5.8 CARE OF CHILDREN WHO ARE UNDERWEIGHT OR WASTED


SESSION LEARNING OBJECTIVES Discuss care and support of underweight or wasted and severely

underweight or severely wasted children.


Step 1: Review the learning objective for this session. Step 2: Discuss the monitoring of growth problems, emphasizing early

intervention to prevent severe underweight. Most of the content for this section is relayed through Exercise 5.

Step 4: Facilitate Exercise 8: Managing Growth Problems. Step 5: Discuss the care of children with growth problems, focusing on the

identification of underweight or wasted and severely underweight or severely wasted children and the importance of immediate action and referrals.


Healthcare workers are strongly encouraged to use growth monitoring to detect growth problems early.

Early intervention at first sign of a growth problem can prevent the problems associated with underweight.

Children who are severely underweight or severely wasted should be referred to the hospital where they can receive care from a team of medical doctors and dieticians.


MANAGING GROWTH PROBLEMS


To encourage discussion, ask participants: What are your experiences managing growth problems? What questions do you ask the caregivers of children whose weight is faltering? What advice do you provide these families? In your experience, what has worked? What has not worked?

As mentioned in Session 5.1, children may present with inadequate growth rates or growth faltering before the symptoms of chronic disease or disability can be identified. Because growth faltering may be the first sign of HIV progression in children, as soon as growth faltering is identified: Evaluate immune status, conduct clinical staging, and initiate ARV therapy if eligible

(Clinical stage 2, 3, or 4 if less than one year of age; Clinical stage 3 or 4 if over the age of one year — refer to guidelines for immune status and other criteria).

If the child is already on ARV therapy, discuss adherence and side-effects; refer to an HIV specialist to consider changing to a second line ARV therapy regimen.

When weight “falters” or the growth curve “flattens” and is no longer parallel to the z-score line (see Figure 5.9: Diagrams of Adequate Growth and Growth Faltering), there is a critical need for clinical and nutritional intervention. If intervention does not occur soon enough, the consequence may be severe, development affected and treatment more extensive and complex. The objective of growth monitoring and promotion efforts, therefore, is to prevent the need for extensive intervention.


Facilitate Exercise 8. In previous sessions, assessing growth and growth faltering was introduced. In the following exercises, the participant will integrate their knowledge of growth assessment with newly acquired skills to provide supportive nutrition intervention for children exhibiting signs of slowed growth.

Exercise 8: Managing Growth Problems Paired group work: participants break into pairs

Purpose To provide participants with an opportunity to assess growth problems and to identify areas for nutrition management.

Duration 45 minutes

Materials Growth Monitoring Case Studies Supplement

Introduction This exercise will provide participants with experience assessing


reasons for growth faltering and developing interventions for inadequate growth.

Activities

Ask participants to break into pairs. Assign each pair one or two case studies (depending on time).

Tebogo and Tumelo, Josiah, Nelson, Nomble, Mamello, Kefilwe, Siphiwe, Abraham

First ask the pairs to plot the measurements on the appropriate chart.

Then, using the case study table as a guide, have the pairs take 10 minutes to role play a consultation between the healthcare worker and the caregiver about the child’s growth.

Have the pairs keep notes on the topics they discuss and the questions the healthcare worker poses. They can then fill in the responses in the case study table together.

Ask the group to re-convene. Then ask someone from each pair to present their case study and share important points or challenges that came up in the role play.

Debriefing Ask the groups if they would like to add anything. Compare the groups’ responses to those below.

Record key points on flip chart for the group to review. In your debriefing, stress the importance of routine monitoring to

assess growth faltering as soon as it occurs. Early intervention prevents the more serious problems associated with underweight and severe underweight.

CARE AND SUPPORT FOR UNDERNOURISHED CHILDREN WITH HIV INFECTION


To encourage discussion, ask participants: Has anyone diagnosed a child as underweight? If so, how did you know the child

was severely underweight? When you identify a child who is underweight, what do you do? What education do you provide? Where do you refer him/her? If that child was HIV-infected, what might happen if you wait till the next visit

before you intervene? Does anyone have any experiences with severely underweight children that they

would like to share? Interventions for children who are underweight (or “wasted” if using the weigh-for-length/height growth curve) are based on whether the child is considered “underweight/wasted” or “severely underweight/severely wasted.” In underweight and severely underweight children, a supplemented diet should be initiated carefully with the support of experienced healthcare workers. These children are


at risk of re-feeding syndrome — metabolic shut down from feeding too much and too quickly when severely undernourished. Interventions for children who are underweight or wasted are listed in Table 5.12. Table 5.12: Intervention for underweight and follow up care for severely underweight

Intervention for children who are underweight/wasted Follow up care for children who are severely underweight/wasted

Consider the following interventions for children who are underweight: Address nutrition-related symptoms. Treat concurrent medical issues, including deworming. Ask about treatment for HIV infection, if the child is HIV infected, ask is she or he

is seeing a healthcare worker at the ARV clinic. If not, refer for HIV-related care immediately.

If the child is on ARV therapy, enquire about adherence. When did you (your child) start ARV therapy? How often have you taken your medicine this past week? How many times did you take your medicine yesterday? What, if any, side-effects have you had? What have they done to address the side-effects? Reassure the caregiver that most side effects subside within a matter of weeks.

If adherence is good, and no other underlying medical cause can be found, consider the possibility that the child might be failing her or his first line regimen. Consider referring to the ARV clinic to consider second line therapy.

Based on the nutrition assessment, provide home and clinic-based education to support changes in food choices, cooking and eating. This could include interventions such as gardening and decreasing food spending so that funds last longer (e.g. consume plant-based sources of protein if the client is eating a lot of meat).

Based on the nutrition assessment, discuss food hygiene. Provide or recommend (or refer caregiver to a food program) food supplementation,

such as Philani (which comes in chocolate, strawberry and vanilla) or Pelargon. See Session 5.6 for additional information about referrals.

Provide or recommend a micronutrient supplement, if available and affordable. SEVERELY UNDERWEIGHT (MARASUMUS) Urgently refer severely underweight children to the hospital or an appropriate

rehabilitation facility. The younger the child, the more urgent the referral; infants are at higher risk of serious illnesses or mortality compared to older children. Children who are severely underweight need to be in the care of healthcare staff experienced in the treatment of undernutrition.

Check for and attend to complications that might lead to death: If the child has a very low body temperature (below 35 degrees centigrade), keep

the child warm. If the child is dehydrated or has diarrhoea, give diluted oral hydration solution. If the child has hypoglycaemia (characterised by drowsiness and stupor), treat per

Integrated Management of Childhood Illness (IMCI) guidelines. Provide broad-spectrum antibiotics to all children with severe undernutrition.

For children who were hospitalised, upon discharge, encourage caregivers to: Feed the child frequently with energy and nutrient-dense food and supplements. Involve the child in play or stimulation to foster the child’s development.


Take the child for regular follow-up to ensure the child completes immunisations, receives monthly vitamin A supplementation every six months, and undergoes monthly growth monitoring.

See a social worker if healthcare workers suspect a child’s severe undernutrition was related to problems that might require social intervention.

Follow-up care for children who are severely underweight are listed in Table 5.12: Intervention for underweight and follow up care for severely underweight.

FACILITATOR INSTRUCTIONS:

Review module learning objectives. Review the summary of key points and ask participants if there are any final

questions before ending the module.

MODULE 5 KEY POINTS

The objective of growth monitoring and promotion efforts is to support parents to ensure their child’s growth rate is adequate.

Recognising when children do not grow at appropriate rates is critical to understanding the health of children.

Growth monitoring is important for all children, not just those living with HIV. Accurate measurement and plotting is critical to identifying and addressing

slowed growth in children living with HIV. A nutritional assessment — which uses medical and social history, information

from the physical examination, information from client interviews and laboratory investigations — provides valuable information about a child’s dietary intake and food norms and provides clues to addressing slowed growth rates.

In children with HIV, growth faltering may indicate disease progression or treatment failure.

Infants, children, and adolescents need additional calories to support growth. Children with HIV need even more calories to compensate for the toll of HIV infection. If this increased demand is not met, the child will be undernourished.

Poor nutrition weakens the immune system and makes it difficult for children living with HIV to fight infections and to grow properly. Good nutrition, on the other hand, can help children living with HIV fight infections, treat symptoms, maximise benefit from ARV therapy and slow progression of disease.

The 24-hour recall is an important tool to assess diet patterns and nutrient adequacy, particularly among caregivers who cannot complete diet logs. This method provides valuable insight into actual food intake, and with the inclusion of an evaluation portion, gives the healthcare worker specific guidance on how best to approach and supplement the child’s diet.

People living with HIV are at higher risk of getting sick from food that has not been prepared or stored properly. It is important to work with families in a respectful way to improve their food storage and hygiene practices.

Find ways to include children in discussion of food, nutrition and food hygiene.


Parents and caregivers should be educated about the side effects of anti-retroviral medicines, particularly as they can affect adherence.

Traditional healers play an important role in South Africa’s response to HIV — they can provide support, encourage practices that reduce transmission and stigma, and support adherence to ARV therapy regimens.

Because most traditional therapies have not been subjected to structured formal research, it is important that they are avoided or, at least discussed with a healthcare worker for any known interactions with ARVs.

Many common nutrition-related symptoms can be managed through food-based interventions.

Nutrition counselling is communication with clients that provides an opportunity to gather information about the child’s problems and circumstances, praise practices that are healthy, offer information and make recommendations.

Because it is not possible for one organisation to provide the wide range of services needed by families, it is essential that healthcare workers are familiar with the local organisations that provide complementary services. It is also important that healthcare workers can refer clients to these services.

Healthcare workers are strongly encouraged to use growth monitoring to detect growth problems early.

Early intervention at first sign of a growth problem can prevent the problems associated with underweight.

Children who are severely underweight or severely wasted should be referred to the hospital where they can receive care from a team of medical doctors and dieticians.


APPENDIX 1 BODY MASS INDEX (CHILDREN AGE 0-5 YEARS) AND Z-SCORES

BODY MASS INDEX (BMI)

BMI is a number that associates a person’s weight with her or his height/length. BMI can be a useful growth indicator when it is plotted on a graph against a child’s age. BMI-for-age is similar to weight-for-length/height and is useful for screening for overweight and obesity. BMI is calculated as follows: Weight in kg ÷ squared length/height in metres Another way to show the formula is kg/m2. BMI is

rounded to one decimal place. Use a length measurement for a child less than two

years old and a height measurement for a child age two years or older. If necessary, convert height to length (by adding 0.7 cm) or length to height (by subtracting 0.7 cm) before determining the child’s BMI.

CALCULATING BMI

Using a calculator If you have a calculator with an x2 button, it is relatively simple to calculate a child’s BMI as follows: 1. Type in the weight in kg (to the nearest 0.1 kg). 2. Press the / or ÷ sign. 3. Type in the length or height in metres. (This will require expressing centimetres as

metres; for example, 82.3 centimetres is expressed as 0.823 metres.) 4. Press the x2 button. The height squared is displayed. 5. Press the = button. The BMI is displayed. 6. Round the BMI to one decimal place and record the BMI on the Road to Health

booklet. If your calculator lacks an x2 button, follow steps 1-3, repeat steps 2 and 3, and then press the = button to display the BMI. If you have no calculator, consult the BMI table that follows. USING THE BMI TABLE 1. Find the child’s length or height (in centimetres) in the far left column of the table. If

the exact measurement is not shown, select the closest one. If the child’s measurement is halfway between those shown, select the next higher measurement.

2. Look across the row to find the child’s weight. If the exact weight is not shown, select the closest one. If the weight is halfway between those shown, consider it “on the line.”

BMI BMI stands for body mass index; a number that indicates a person’s weight in proportion to height/length, calculated as kg/m2.


3. Trace your finger upward from the weight to find the child’s BMI on the top row of the table. (Or you can trace downward, as the BMIs are also on the bottom row.) If the weight was “on the line,” the BMI will be halfway between those shown, e.g. 15.5 if between 15 and 16.

4. Record the BMI. Reminder: If a child has oedema of both feet, do not determine the child’s BMI, as his weight is unrealistically high due to fluid retention. Refer the child with oedema of both feet for specialised care.

TRENDS IN BMI-FOR-AGE

BMI does not normally increase with age as do weight and height. Typically an infant’s BMI goes up sharply as the infant rapidly gains weight relative to length in the first six months of life. The BMI comes down in later infancy and remains relatively stable from age two to five years, see the BMI-for-age charts that follow the calculator.

Z-SCORES

Z-score lines appear several on the growth charts, often replacing the more familiar percentiles lines. The z-score line is a handy reference that shows whether or not the child’s weight (or height or head circumference, etc.) is within the expected range for a healthy child her or his age. It is based on mathematical calculations that take into account the average weight and variation in weight for children at various ages. Most healthy children’s measurements will fall within 2 z-score lines above and 2 z-score lines below the median (average). However, danger signs differ for different measurements. Be sure to refer to the guidelines for each measurement to determine when the child’s measurement should put you on alert as to the child’s growth.


APPENDIX 2 ROAD TO HEALTH BOOKLET (BOYS)


APPENDIX 3 ROAD TO HEALTH BOOKLET (GIRLS)


The Road to Health growth charts are re-printed here for informational and educational purposes only. Do not photocopy this chart for clinical use. For clinical purposes, always use an original, A3 size (green print) Road to Health booklet distributed by the national Department of Health.


APPENDIX 4 HEAD CIRCUMFERENCE GROWTH CHARTS (BOYS AGE 0-5 YEARS)

Available from: http://www.who.int/childgrowth/standards/chts_hcfa_boys_z/en/index.html


APPENDIX 5 HEAD CIRCUMFERENCE GROWTH CHARTS (GIRLS AGE 0-5 YEARS)

Available from: http://www.who.int/childgrowth/standards/chts_hcfa_girls_z/en/index.html


APPENDIX 6 COMMUNICATION SKILLS CHECKLIST

As you observe your colleagues role play, indicate the communication skills they use by placing a check in the appropriate box.

SKILLS AND TECHNIQUE CHECKLIST Skill Specific Strategies, Statements, Behaviours ( )

Shows a relaxed and natural attitude Adopts an open posture Leans forward when talking Makes eye contact Sits squarely facing client

Skill 1: Use helpful non-verbal communication

Other (Specify) Uses open-ended questions to get more in-depth

information from the client

Asks questions that reflect interest, care and concern rather than interrogation

Skill 2: Ask open-ended questions

Other (Specify) Nods, smiles reassuringly; uses encouraging responses

(such as “yes,” “okay,” “Mmm,” or “aha”)

Clarifies statements effectively Takes time to summarise information the client shares Comments on client’s challenges while also indicating

client’s strengths

Skill 3: Use responses and gestures that show interest

Other (Specify) Reflects emotional responses back to the client using

different words Skill 4: Reflect

back what the mother says Other (Specify)

Demonstrates empathy: shows an understanding of how the client feels

Avoids sympathy. Sympathy is when the HCW moves the focus to her self (“I know how you feel, my sister has HIV.”) whereas empathy focuses on the client (“You’re really worried about what’s going to happen now that you’ve tested HIV-positive.”)

Skill 5: Empathize—show that you understand how she feels

Other (Specify) Avoids judging words such as good, bad, correct, proper,

right, wrong, adequate, inadequate, satisfied, sufficient, fail, failure, succeed, success, etc.

Used words that build confidence and gives support (e.g., recognises and praises what a mother is doing right)

Skill 6: Avoid words that sound judging

Other (Specify):

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RESOURCES FOR FURTHER INFORMATION

Children’s Rights Centre (2007) You and Your Child with HIV-Living Positively.

http://www.childrensrightscentre.co.za/site/awdep.asp?depnum=20723 Department of Social Development and Unicef-South Africa Parental/Primary Caregiver

Capacity Building Training Package-Low Literacy Version (2008). http://www.unicef.org/southafrica/resources_920.html

Fanta Project (2008) Nutrition and HIV/AIDS: A Training Manual for Nurses and

Midwives. http://www.fantaproject.org Hendricks, M. K., Eley, B., Bourne, L. T. (2007). Nutrition and HIV/AIDS in infants

and children in South Africa: implications for food-based dietary guidelines, Blackwell Publishing

Kale, R. (1995). “South Africa: Traditional healers in South Africa: a parallel healthcare

system.” British Medical Journal 310(6988): 1182-1185. South Africa Department of Health (2007) DRAFT Guidelines for Management of

Food-Borne Illness. (2007)-DRAFT) http://www.doh.gov.za/docs/index.html South Africa Department of Health, DRAFT (2009) National Nutrition and HIV/AIDS

Guidelines for Service Providers to People Living with HIV/AIDS. Spool, S., Torino, J. (2008) Food Insecurity, Malnutrition and HIV/AIDS Treatment: A

Global Perspective. Gay Men's Health Crisis UNICEF. “Community Help for Children Living in and HIV+ World. Bringing Hope

to Orphaned Children.” http://www.childrensrightscentre.co.za/site/awdep.asp?depnum=20723

USAID/Food and Nutrition Technical Assistance/AED (2008) Nutritional care and

support for people living with HIV and AIDS: A training course. http://www.aidsbuzz.org/component/sobi/?sobiTask=sobiDetails&catid=12&sobiId=94

Wanke, C., (2004). Pathogenesis and Consequences of HIV-Associated Wasting. Journal

of Acquired Immune Deficiency Syndromes: 1 December 2004 - Volume 37 - Issue - pp S277-S279. Supplement Article

WHO (2008). “Traditional medicine, Fact sheet No. 134.” from

http://www.who.int/mediacentre/factsheets/fs134/en/


REFERENCES

1 WHO (2008). “Training Course on Child Growth Assessment.” Geneva, WHO.

Available at http://www.who.int/childgrowth/training/en/ 2 WHO (2008). “Training Course on Child Growth Assessment.” Geneva, WHO.

Available at http://www.who.int/childgrowth/training/en/ 3 WHO Training Course on Child Growth Assessment from 2008 4 WHO (2008). “Training Course on Child Growth Assessment.” Geneva, WHO.

Available at http://www.who.int/childgrowth/training/en/ 5 WHO Training Course on Child Growth Assessment from 2008 6 WHO (2008). “Training Course on Child Growth Assessment.” Geneva, WHO.

Available at http://www.who.int/childgrowth/training/en/ 7 WHO Training Course on Child Growth Assessment from 2008 8 “Measuring and Plotting using the new UK-WHO Growth Charts.” Available at

http://www.rcpch.ac.uk/Research/Growth_Charts_Education_Training_Resources 9 WHO (2009). “Joint Statement: WHO Child Growth Standards and the Identification

of Severe Acute Malnutrition in Infants and Children.” http://whqlibdoc.who.int/publications/2009/9789241598163_eng.pdf

UNICEF (2005). Emergency Field Handbook 10 http://www.who.int/childgrowth/training/en/ 11 Road to Health booklet (Appendix 2) 12 FANTA, Jennifer Coates, Patrick Webb and Robert Houser. “Measuring Food

Insecurity: Going Beyond Indicators of Income and Anthropometry.” November 2003

FANTA, Anne Swindale and Paula Bilinsky. “Household Dietary Diversity Score

(HDDS) for Measurement of Household Food Access: Indicator Guide.” Version 2 September 2006

13 Walker and Watkins Eds. “Nutrition in Pediatrics: Basic Science and Clinical

Applications.” BC Decker 1997 ISBN 1-55009-026-7


14 François-Xavier Bagnoud Centre, UMDNJ 2009 15 Hendricks, M.K., Eley, B., & Bourne, L.T. (2007). Nutrition and HIV/AIDS in infants

and children in South Africa: Implications for food-based dietary guidelines. Maternal and Child Nutrition, 3, 322-333.

16 Eley, B.S., Davies, M., Apolles, P., Cowburn, C., Buys, H., Zampoli, M., et al. (2006).

Antiretroviral treatment for children. Southern African Medical Journal, 96, 988-993. 17 Piwoz, E. and Preble, E. 2000. “HIV/AIDS and nutrition: A review of the literature

and recommendations for nutritional care and support in sub-Saharan Africa.” Washington, DC: SARA Project, Academy for Educational Development http://sara.aed.org/sara_pubs_list_usaid_5.htm

STELLENBOSCH UNIVERSITY,FACULTY OF HEALTH SCIENCES

3rd Floor, Waterside Place, South Gate,

Tyger Waterfront, Carl Cronje Drive, Bellville, Western Cape 7530

T: +27 21 918 4376 F: +27 21 918 4389 Toll Free: 0800 050 050

Website: www.sun.ac.za/southtosouth

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