Management of diarrhea and nutritional support
HIV infection in children is often thought to be a rapidly and uniformly lethal disease. In Rwanda, however, 40% of children with perinatal infection survive for 5 years without antiretroviral treatment, and there are many children in sub-Saharan Africa with vertically acquired HIV infection attending schools and growing into adoles-cence.112 Optimizing the quality of life for these children is a necessary challenge, especially when the option of effective antiretroviral therapy is absent. The approaches outlined below are intended for developing countries.
In most clinical settings in southern Africa it is not possible to investigate children presenting with recurrent or persistent diarrhea extensively. Using a syndromic approach for managing diarrhea in both HIV-infected and uninfected children is therefore appropriate. The WHO/UNICEF Integrated Management of Childhood Illnesses (IMCI) recommends that children with a history of persistent diarrhea and/or reported weight loss in the previous 3 months should be assessed for possible HIV infection.113 Where there are no specific guidelines for HIV-infected children, the WHO guidelines for the management of severe malnutrition, including persistent diarrhea, are helpful.
An approach for resource-poor countries would be:
- 1) Assess for and correct dehydration, hypo-glycemia, hypothermia and electrolyte disturbances, especially K+ deficiency;
- 2) Treat concurrent bacterial infections, e.g. pneumonia, Pneumocystis carinii pneumonia (PCP) and urinary tract infection, and exclude TB. This often means giving antibiotics empirically, e.g. cefuroxime, gentamycin and cotri-moxazole;
- 3) Start low lactose (< 3.2 g/kg) containing feeds such as F-75 (WHO) and porridge;
- 4) Provide vitamin A, zinc and multivitamins, including folate. See below for comment on zinc supplements;
- 5) If diarrhea persists then test stools for lactose intolerance using Clinitest® tablets;
- 6) If Clinitest is positive then exclude all lactose from diet - use milks containing maltodextran as the main carbohydrate;
- 7) If Clinitest is negative then send repeat stools for routine microbiological assessment, including for Shigella, non-typhi Salmonella, Cryptosporidium, microsporidia and TB. Treat accordingly. Cryptosporidia may be shed intermittently; three stools should be sent to exclude diagnosis. Experienced staff are required to identify cryptosporidia and microsporidia on routine stool analysis. Prolonged fluid and nutritional support is often required for patients with cryp-tosporidiosis;
- 8) If no pathogen is identified then treat for bacterial overgrowth, e.g. cholestyramine for 5 days and neomycin for 3 days;
- 9) If diarrhea persists check for monosaccharide intolerance; test for glucose in stool using Clinitest or Glucostix®. If positive, check for excessive intake of oral rehydration solution (ORS). Use maltodextran (glucose polymer) containing feeds and deliver milk by continuous slow infusion through a nasogastric tube. Use plain boiled water for oral rehydration rather than ORS. Only revert back to bolus feeds once the stool becomes formed again and glucose is not present. This takes longer in children who are more wasted or who have severe diarrhea;
- 10) Where resources are available, perform upper gastrointestinal endoscopy to increase the microbiological diagnostic yield. If visible or microscopic blood is present in stools then perform sigmoidoscopy for biopsy and culture;
Management of diarrhea and nutritional support 121
- 11) Where there is persistent pyrexia consider CMV colitis and exclude TB;
- 12) If no cause for persisting diarrhea is evident then consider antimotility drugs such as loperamide (HIV enteropathy is a diagnosis of exclusion);
- 13) Older children should be asked about abdominal pain and on these occasions underlying opportunistic infections such as TB, Cryptosporidium or CMV should be excluded; opiates such as codeine phosphate may be helpful;
- 14) Attention must be given in the weeks following discharge to restoring, as much as possible, any weight loss that has occurred. It is often very difficult to achieve this during hospitalization, and in busy hospitals significant weight gain cannot be used as a criterion for discharge (see Nutrition, below).
Parenteral nutrition is not generally feasible in most developing countries because of the risk of systemic infection and metabolic complications.
When children are admitted with evidence of clinically advanced HIV infection such as diarrhea and severe wasting, clinicians and carers must consider what is reasonable and right for the child. The first admission with diarrhea often results in HIV testing. Many mothers discover for the first time that both she, and her child, are HIV-infected. In this situation it is appropriate to use all resources available to ensure that the child recovers and is able to go home. However, the treatment paradigm and objectives for care often change when the child has suffered several admissions, and the family has had some time to adapt to the diagnosis. In the absence of antiviral drugs, relieving discomfort becomes the overriding priority, and being less aggressive when complications such as concurrent severe bacterial infections intervene may be more caring for the child.
In resourced settings
While the same principles apply, the use of invasive diagnostic methods, i.e. upper and lower intestinal endoscopy, should be used early to determine whether a treatable enteric pathogen is present. Parenteral feeding may be a safe option if severe malabsorption is present. Antiretroviral drugs should be initiated if the child has not been previously treated.
Micronutrients and HIV-related diarrhea
Multiple micronutrient deficiencies have been reported in both HIV-infected adults and children with, or without, diarrhea. Biochemical indicators of vitamin and trace element status may be misleading and reflect redistribution or acute-phase responses rather true body depletion. A few studies have shown that micronutrient supplementation in HIV-infected or exposed children is associated with improved morbidity or immune function.114-116 In children uninfected with HIV, zinc supplementation reduces the incidence, duration and severity of acute and chronic diarrhea and promotes recovery of the mucosal lining.117,118 This effect has not so far been demonstrated in HIV-infected children.
Vitamin A does not seem significantly to influence the course of acute or persistent diarrhea in un-infected children, but does decrease the severity and likelihood of recurrence.119 HIV-infected children with persistent diarrhea should receive vitamin A (0-6 months, 50 000IU; 6-12 months, 100 000 IU; >12 months, 200000IU daily for 2 days), zinc sulfate or gluconate 2 mg/kg for 2 weeks and multivitamin preparations including folate for 2-4 weeks.
Much of the impact of diarrheal illnesses and repeated opportunistic infections on the health of HIV-infected children is mediated by its effect on nutrition. Loss of lean body tissue is consistently seen in adults and children with advanced disease and is a strong predictor of death.120 Resting energy expenditure (REE) in adults increases by about 10% once they are infected with HIV, but this does not been seem to be the case in children.53,121 However, even if REE increases modestly, total energy expenditure may not increase, because of inactivity. Rather, weight loss is most likely to be due to decreased energy intake, especially during the recovery period from opportunistic infections. Nutritional interventions, however, have generally only reversed weight loss through gain of fat rather than lean body tissue. There is work to suggest that different opportunistic infections may have differential effects on nutrition with some being capable of impairing anabolism and effective utilization of energy from food.
WHO currently recommends that infected children should increase their overall energy intake by about 10% in order to maintain normal health, growth and activity. In chronic illness such as TB infection or chronic lung disease, energy intake should increase by 25-30%. During acute illnesses, particularly when recovering from acute weight loss, these requirements may increase to 50-100% extra energy. Protein should represent about 10-15% of energy. These goals should ideally be achieved through dietary approaches rather than by specialized supplements which may not be available or affordable in most developing countries.122
Surgical aspects of HIV infection
The prevalence of HIV disease among pediatric surgical patients in southern Africa has increased dramatically and is frequently considered as part of the differential diagnosis. Abdominal pain is not uncommon in adults with HIV, but there are no data on children. An underlying pathological cause can be identified in most cases123 and include TB abdomen, cryptosporidia and CMV. There are four common surgical manifestations of gastrointestinal HIV disease: destructive lesions, opportunistic infections, primary peritonitis and tumors.
Rectovaginal fistulae are an extremely common presentation of HIV disease in female infants.124,125 In the past this was treated with a defunctioning colostomy followed by closure of the fistula. Recurrence was frequent. Antiretroviral therapy may improve surgical results, but in the absence of such treatment it is generally better to leave the fistula alone.126 In males, there is the less common presentation of a rectourethral fistula which always requires surgical repair.
Occasionally stricture formation may follow sclerosis of the lower esophagus after repeated ulcerative disease such as CMV or invasive candidiasis.
Intestinal perforations due to CMV are described above.104 HIV occasionally presents as cancrum oris, where early treatment with penicillin and metronidazole may help, but excision and reconstruction may be required for large areas of full-thickness skin and tissue loss.
This is sometimes seen in the older child who presents with a clinical picture suggestive of appendicitis. At surgery an odorless pus is found in the abdomen; pneumococcus is often isolated.
Kaposi's sarcoma in the gut may present with rectal bleeding, and other less common smooth-muscle tumors may rarely present as an intussusception and intestinal obstruction.127,128
Condyloma accuminata that may vary in size from isolated lesions to large pancake lesions can cover the perineum and genitalia. The more extensive lesions cause severe discomfort and problems with local hygiene. Isolated lesions may respond to podophyllin, but diathermy results in annular scarring and anal stenosis. Treatment with interferon may be helpful.
Sialadenitis is a frequent complaint. Parotid size may increase and decrease intermittently, and pain may be due to superimposed bacterial infection, TB, bleeding into cysts or malignant change. Acute pain should be treated with antibiotics and analgesia; if the parotid continues to enlarge and is painful, then fine-needle or open biopsy should be performed to exclude TB or malignant change. Corticosteroids may be helpful.
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