Pediatric Nutrition in Practice

HIV and AIDS 175

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feeding (to reduce the high transmission risk).
In resource-limited settings, the conditions un-
der which replacement feeding is preferred are
commonly referred to as AFASS – affordable,
feasible, acceptable, sustainable and safe. The
acronym is now described in everyday language
in the 2010 WHO recommendations ( table  2 )
[1].

Other Measures
The WHO recommends home pasteurization of
breast milk only as an ‘interim’ strategy, e.g. if
ART is temporarily unavailable or the mother or
infant is too ill to breastfeed [1]. Adequately heat
treated, expressed milk from HIV-positive
mothers does not transmit HIV and remains nu-
tritionally and immunologically superior to in-
fant formula. Wet-nursing may be considered in
communities where this option is accepted. The
wet nurse needs to have a negative HIV test be-
fore and 6 weeks after starting. Experience with
breast milk banks in Latin America, particularly
Brazil, has been positive, although limited by the
extent of coverage of the at-risk population.
HIV-infected caregivers should be warned
against the common practice of providing chil-
dren with premasticated (prechewed) food as
this practice has been implicated in HIV trans-
mission [5].

Feeding the HIV-Infected Child Not on ART

Nine of 10 studies on HIV-infected children, con-

ducted in resource-constrained countries, report-

ed low height-for-age (stunting), and all 10 de-

scribed poor weight gain [6]. Untreated HIV in-

fection is characterized by increased resting

energy expenditure, and decreased appetite, di-

gestion of food and absorption of nutrients. HIV-

infected children often have a range of micronu-

trient deficiencies.

At their first contact with a health care profes-

sional, children with HIV should have their an-

thropometric status (e.g. weight, height, head cir-

cumference and arm circumference) measured,

and nutritional problems screened for. A dietary

history should be obtained and compared with

estimated needs to assess adequacy of intake.

Women who have an HIV-infected child

should be strongly encouraged to breastfeed.

Since it is difficult to calculate the precise caloric

needs of an HIV-infected child, the energy in-

takes for HIV-infected children experiencing

weight loss need to be increased by 50–100% over

established requirements for otherwise healthy

uninfected children [7].

After 4–6 months, complementary foods should

be increased to as much as can be tolerated. If the

child is eating solids, adding a high-fat supplement

Ta b l e 2. Conditions needed to safely replacement feed

Mothers known to be HIV infected should only give commercial infant formula milk as a

replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status if

specific conditions are met. The mother or caregiver:

• has access to safe water and sanitation in the home and in the community;


• can reliably provide sufficient infant formula milk to support normal growth and
  development of the infant;


• can prepare it cleanly and frequently enough so that it is safe and carries a low risk of
  diarrhea and malnutrition;


• can, in the first 6 months, exclusively give infant formula milk;


• obtains the family’s support for the practice, and


• can access health care that offers comprehensive child health services.

Source: WHO [1].

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 173–177
DOI: 10.1159/000360332