Nutrition Guidance for Positive Children

Introduction
The nutritional status of a child has unique considerations and therefore requires unique interventions. When a child is HIV-infected, good nutrition not only promotes healing, prevents infections and associated wasting, but is also vital to optimal growth and development and is frequently more difficult to achieve. This section attempts to help you identify and resolve common situations that could adversely affect the HIV-infected child. This includes:

Quick Nutrition Screen A set of 20 "Quick Nutrition Screen" questions was developed and is located on the next page. Each question is addressed on pages that follow and can be used as handouts. Nutrition Tip Sheets For some concerns there is more information provided on a "tip" page. The "tip" page is mentioned within the text of the answers to the questions from the Quick Nutrition Screen. Topics of the tip sheets include:
1. 2. 3. 4. 5. 6. 7. Dental Care Feeding Your Sick Child Constipation Snacks and High Calorie Suggestions The Toddler and Pre-School Aged Child Eating Behaviors Giving Medications Avoiding Foodborne Illness

For the Clinician In addition, there is a special area designed for the clinician that addresses:
1. General Monitoring 2. Pediatric Enteral and Parenteral Nutrition 3. Complementary Nutritional Therapies

For More Information see References UPDATE 10

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Nutrition Guidance for Positive Children

Quick Nutrition Screen Questions
For each statment below, circle the YES column for those that apply to you and the NO column for those that do not.

1. 2. 3. 4. 5.

My child has not gained enough weight or has lost weight............. YES My child is eating less than usual .................................................... YES My child does not eat beef, pork, chicken, turkey or fish ............... YES My child does not eat fruits and/or vegetables ................................ YES My child does not drink milk or eat dairy products ........................ YES (e.g., cheese, yogurt, ice cream) 6. My child does not eat whole-grains ................................................. YES (whole grain breads and cereals) 7. My child drinks more than 8 ounces of soda, fruit juice and soft drinks or tea/day................................................................. YES 8. My child is over 2 years old and continues to drink from a bottle .................................................................................... YES 9. My child has gas, bloating or stomach aches a lot .......................... YES 10. My child has loose or watery bowel movements or is constipated ............................................................................. YES 11. My child complains that it hurts to chew or swallow .................... YES 12. My child does not take a vitamin................................................... YES 13. My child takes extra vitamins or herbs .......................................... YES 14. Our family has difficulty getting enough food .............................. YES 15. We do not have a place to cook or to keep our foods cold ............ YES 16. I often don't feel like eating, food shopping or cooking ................ YES 17. My child has high blood cholesterol.............................................. YES 18. My child has high blood pressure .................................................. YES 19. I have a hard time getting my child to take the medicines ............ YES 20. My child does not show interest in active play ............................. YES

NO NO NO NO NO NO

NO NO NO NO NO NO NO NO NO NO NO NO NO NO

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #1

More information about your YES answers

My child has not gained enough weight or has lost weight Continued gradual growth and weight gain and a healthful diet are extremely important in maintaining the best possible health for normal growth and development of all children. When a child is infected with HIV, normal growth and weight gain become even more important. Not only is the child's body growing, it is also dealing with the extra demands and effects of the disease, as well as coping with possible side effects of the treatment. A Registered Dietitian / Nutritionist can help you identify the possible causes of the poor growth and weight gain, and help check on your child's progress on his/her "Growth Curve" that your health care provider keeps. This provides a way to see what your child should weigh. It can also show that if what you are doing to increase dietary intake is helping your child's growth get "back on track".

Common reasons for eating problems include:

Sore mouth/throat - see Nutrition Tip Sheets #2 and #4 for suggestions Nausea and vomiting, upset stomach, diarrhea, constipation - see Nutrition Tip Sheets #2 and #3 for suggestions Emotional or behavioral problems - consult your primary care provider for a referral for psychological assessment and counseling Mealtime atmosphere - see Nutrition Tip Sheet #5 for suggestions Picky eater - see Nutrition Tip Sheets #4 and #5 Sick a lot - see Nutrition Tip Sheets #2 and #4

Be sure to call your health care provider if your child has diarrhea and/or a fever, especially in very young children.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #2

More information about your YES answers

My child is eating less than usual

Eating behaviors:
All toddlers and pre-school aged children are learning to be independent, so it is common for food likes and dislikes to become bigger issues at this age. Caregivers must provide not only healthy foods to meet the child's growing needs, but also establish a comfortable eating setting. In this way, healthful eating attitudes and habits can develop. See Nutrition Tip Sheet #5 for suggestions on developing good eating habits and attitudes.

Getting your child to eat when they do not feel well:

Side effects of illness and treatment vary with each child and it is not possible to predict how the disease or treatment may affect a child. Tips that help in managing illnesses and side effects of treatment also vary with each child. Some approaches and foods that work with one child may not work with the next. See Nutrition Tip Sheets #2 and #6 for ideas to control the side effects of treatments and make the best of nutrition during these difficult times.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #3

More information about your YES answers My child does not eat beef, pork, chicken, turkey or fish Children with HIV should eat a high protein diet. Animal foods such as meat, fish, poultry, and dairy products like milk, cheese and yogurt are all good sources of protein. At the age of nine months, most children will accept pureed meats. Children should be about one year of age when they are offered table meats. At one, most children can eat tender meats. Sometimes children with HIV require a little extra time to get ready to eat different types of solids. When a child shows up and down chewing and is able to move food to the sides of his/her mouth then he/she is ready for small bites of soft meats. If your child has reached 15 months of age and does not show these signs, then you should consult your physician or a Registered Dietitian or other nutrition professional. Sometimes small children and toddlers do not eat different types of meats, fish and poultry because they do not like the texture or the way that food feels in his/ her mouth. This kind of problem requires a little more time and patience with feeding. Start by offering very soft, well-cooked or stewed meats. Try adding them to his/her favorite foods in very small pieces. For example, add a small amount of chicken, turkey or beef to soup, or add these foods to mashed potatoes or pasta dishes. As they become used to the taste and feel, they will accept larger pieces. See Nutrition Tip Sheet #5 for more ideas on how to feed your toddler. If your child is not ready or continues to refuse meats even in very small pieces, continue to offer these foods at least once a week. Meanwhile, how can you be sure your child is receiving enough protein in his or her diet? Foods such as scrambled eggs, peanut butter, tofu and cooked beans all are excellent sources of protein and are fine meat substitutes.

The following foods are considered a serving of protein:

1 year-old
Eggs Peanut Butter Cooked Beans & Peas Meat, Poultry, Fish Tofu 1 Not recommended 1/4 cup 1 ounce 1/3 cup

2-3 years old

1 1 Tablespoon 1/3 cup 1 ounce 1/3 cup

4-5 years old

1 3 Tablespoons 1/2 cup 1-2 ounces 1/2 cup

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #4

More information about your YES answers

My child does not eat fruits and/or vegetables A good diet includes at least 5 servings of fruits and vegetables per day. Most children like fruits because of their sweet taste. Vegetables are often harder to get them to eat. See Nutrition Tip Sheet #5 for ideas. The vitamins and minerals found in fruits and vegetables are very important to support the immune system and help fight infections. Fruits and vegetables are also a good source of fiber and water and are important for your childs health and bowel function. See Nutrition Tip Sheet #3.

Add fruit and vegetables to your childs diet by trying the following:
Offer 8 ounces of fruit juice per day (this equals 2 servings of fruit) Serve soups and stews thick with different kinds of vegetables Let your child choose the vegetables he/she wants to add to homemade soups Offer raw fruits with a yogurt dip Offer vegetables with a creamy dressing or dip. Make the vegetables into fun, creative shapes using a paring knife, small cookie cutters, or a ripple cutter Sweeten vegetables such as carrots, winter squash, sweet potatoes, yams or cabbage with a drizzle of maple syrup or orange juice Scatter vegetables on top of pizza or cooked in casseroles Melt a favorite cheese over vegetables, such as cheddar cheese over broccoli or cauliflower Add shredded vegetables such as carrots or zucchini to ground beef and make into patties for burger Add shredded zucchini or carrot to potato pancake batter Puree vegetables in a blender, then add the batter to soup, stews, sauces, or baked products such as muffins, quick breads, or brownies

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Nutrition Guidance for Positive Children

Puree two packages of frozen spinach, thawed and squeezed dry, and one 16-ounce jar of beets, drained; add to devils food cake batter and bake as directed Serve waffles with fruit for dinner Pizza or potatoes can be healthy morning meals Wrap vegetables in biscuit dough. Bake and serve Cut up small pieces of fruit and stir into frozen yogurt, ice milk, or ice cream Serve dried fruit as a treat instead of cookies or candy If most fruits and vegetables are still refused, a vitamin/mineral supplement will help provide the major nutrients missing from the diet.

The following are considered one serving of fruits or vegetables:

9-10 months: 11-12 months: 1-3 years: 4 ounces of fruit juice 6 to 8 tablespoons of mashed/pureed fruits or vegetables 4 ounces of fruit juice 1/2 cup of soft, canned fruits or vegetables, cut-up 4 ounces of fruit juice 1/4 to 1/2 cup of fruits or vegetables 1/2 piece fresh fruit 4 ounces fruit juice 1/2 cup or 1 medium serving of fruits or vegetables 1/2 to whole piece fresh fruit

4 years or older:

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #5

More information about your YES answers

My child does not drink milk or eat dairy products, such as cheese, yogurt or ice cream Some children simply do not like or refuse milk or dairy products. The following is for those children who do not get enough milk and dairy products to meet their body's needs for calcium and other nutrients. For those children, who do not drink milk or eat dairy products because they have symptoms like gas, bloating, cramps and diarrhea when milk products are eaten see Quick Nutrition Screen Question #9, where lactose intolerance is discussed. Everyone, especially children, needs the vitamins and minerals found in milk and milk products. Milk products provide a lot of calcium. This nutrient is necessary to build and keep strong bones and teeth in babies, infants, children, and adults. Normal growth is sometimes a problem with children infected with HIV. Avoiding or not getting these foods in the diet for more than a few months could produce some nutrient deficiencies and create growth and bone development problems. Here are some ideas to add milk and milk products to the diet: Use milk in cooking: Add fluid milk to: Creamed soups Puddings and custards Sauces and gravies Hot cereals Scalloped and au gratin potatoes Add dry milk to: Mashed potatoes Dough for tortillas Bread, biscuits, muffins Meatloaf, meatballs, hamburgers

Note: 1/3 cup of dry milk=1 cup of fluid milk

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Nutrition Guidance for Positive Children

Try milk drinks: Yogurt Smoothie Blend or mix 1 cup of plain yogurt 2 tablespoons of powdered milk Your favorite fruit 1/2 cup of milk Egg Nog Blend or mix 1 cup of milk 2 tablespoons of powdered milk Pasteurized egg substitute Dash of nutmeg Vanilla A little sugar if desired Hot Chocolate Made with milk instead of water Add 1 tablespoon of powdered milk for additional nutrition

Add cheese to favorite foods:

Cooked vegetables, pizza, tacos, enchiladas, nachos, potatoes Chili, chile relleno, lasagna, casseroles, refried beans, salads

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #6

More information about your YES answers

My child does not eat whole-grains (whole wheat bread, whole-grain cereals) Grains are an excellent source of energy, B1 (thiamine) and B2 (riboflavin). Thiamine and riboflavin are important for energy metabolism and a healthy nervous system. People who are HIV infected are more likely to become low in these B vitamins because they are absorbed in the small intestine and stored in the muscle. Malabsorption, diarrhea, wasting, and malnutrition can all contribute to low levels of these vitamins. Grains are an excellent source of fiber. The fiber in whole grains helps normalize the bowels, that is, helps stop constipation and diarrhea. See Nutrition Tip Sheets #2 and #3. The energy (calories) from the grains helps spare the bodys protein for muscle development. Some children prefer not to eat whole grain breads and cereals because they are not familiar with the taste and texture. Let them see you enjoy eating these foods.

Keep these foods on hand and offer them regularly:

Whole grain crackers with cheese or peanut butter Muffins made with whole wheat Whole grain breads for sandwiches and toast Whole grain cereals, waffles, pancakes, tortillas, and pita bread See Nutrition Tip Sheet #5.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #7

More information about your YES answers

My child drinks more than 8 ounces of soda, "fruity" juices or drinks or tea each day Soda, soft drinks and tea are not good sources of nutrition and if consumed in large quantities often replace nutritious foods that will help your child grow, gain weight and stay well. While fruit juice does contain some vitamins and minerals, it usually has only a few nutrients. See Nutrition Tip Sheet #5. On the other hand, "fruity" soft drinks, like Kool-Aid, Hawaiian Punch or Orange Delight contains little or no natural fruit juice and little if any nutrients. Your child needs a variety of nutrients to be able to grow and be healthy.

If your child is at least one year old and can drink milk without problems:
Offer your child between 24 and 32 ounces total of milk each day. If your child is over 2 years old, low-fat milk can be used. Under 2, whole milk is recommended. Limit fruit juice to 8 ounces per day (unless otherwise directed). If your child wants more to drink, offer water. Offer foods that contain a lot of water as well as nutrients such as fresh fruit, puddings, ice cream, frozen yogurt, shakes and fruit slushes.

If your child is at least one year old and cannot drink milk:
See Nutrition Screen Queen #9 Offer your child between 24 oz and 32 oz of Lactaid, or protein and calciumfortified soy milk. There are calcium-fortified rice milks, but because they are so low in protein, they should not be used. You may replace milk with a doctor ordered supplement (Pediasure, Nutren Jr, Resource for Kids). Ask your health care provider.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #8

More information about your YES answers

My child who is over 2 years old continues to drink from a bottle Between their first and second birthday, most children will be drinking from a cup. By this age some children will still want their bottle more for comfort rather than because they are hungry. If your child is able to drink from the cup, he or she does not need a bottle. Try offering stuffed animals or a special blanket to replace the bottle at naptime and bedtime. Continued use of the bottle allows a constant contact of sugary liquid (from juice, punch or milk) with the teeth that causes cavities, pain, and may eventually require dental surgery to have the diseased teeth pulled. See Nutrition Tip Sheet #1. If the child is allowed to drink frequent bottles of juice or milk throughout the day, their stomachs become full of liquids and they have little interest in eating their meals or snacks. Children cannot get all the nutrition that they need from milk and juice. Nutrients that are important for growth and a healthy immune system will be missing from the childs diet. In addition, this is the time of a toddlers life that they should be learning to eat solid foods, drink from a cup and feed themselves. If they are drinking rather than eating most of their nutrition, they are not practicing the skills needed to successfully feed themselves. See Nutrition Tip Sheet #5.

If your child is drinking more than 24 ounces of milk from the bottle per day and is refusing to eat their food, try the following:
Limit milk to 24 ounces per day Limit juice to 8 ounces per day Offer all liquids from a cup before allowing the bottle Don't give liquids at least one hour before meals Offer only 6 to 8 ounces of liquid at the mealtime Praise your child for drinking from the cup and eating by himself Use a sippy cup that can be sealed for travel Talk with your healthcare provider about your concerns
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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #9

More information about your YES answers

My child has gas, bloating or stomach aches a lot The gas, bloating and stomach ache may be caused by lactose intolerance. Other factors that can cause gas, bloating and stomach ache include medication intolerance, gastro-esophageal reflux, or opportunistic infections. It is important to talk with you health care provider to determine the cause of the symptoms. Lactose intolerance means that the body does not have (or have enough of) the enzyme lactase to be able to digest or absorb the carbohydrate called lactose or milk sugar that is found in milk. Those with lactose intolerance have increased gas, abdominal bloating, or diarrhea after eating foods containing lactose. Lactose is found in milk or anything made from milk. This includes cheese, yogurt, ice cream, instant breakfast powder, infant formulas made from cow's milk, and breast milk. The level of lactose intolerance may vary from child to child; some may tolerate cheese and yogurt made with live cultures, but not milk or ice cream, while another may not tolerate any of these. Some fermented dairy products like yogurt, sour cream, buttermilk, or specially treated milks like Lactaid or acidophilus milk may be better tolerated. Non-dairy products such as calcium fortified rice milk, soy milk and soy cheese are also good options. Drinking milk or eating dairy products in small amounts throughout the day may be tolerated better than a large serving all at once. Talk with your Registered Dietitian/Nutritionist about other milk substitutes that may be good for your child.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #10

More information about your YES answers

My child has loose or watery bowel movements or is constipated Diarrhea is defined as 3 or more watery bowel movements per day. It can be caused by a viral or bacterial illness, food allergy or intolerance, by the HIV virus, or by a medication. Make sure to tell your health care provider if diarrhea lasts more than 3 days. It is important that your child drinks plenty of fluid to prevent dehydration, and eats solid foods as tolerated. Sometimes it is helpful to avoid milk and dairy products for a few days. Food or infant formula should not be withheld for more than one day. See Nutrition Tip Sheet #2 for suggestions. Constipation is defined as hard, difficult to pass bowel movements. It is most often caused by not getting enough fluid and/or fiber daily; certain medications can cause it, and physical activity can help to improve "regular" bowel movements. See Nutrition Tip Sheet #3 for suggestions to increase the fluid and fiber in your child's diet.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #11

More information about your YES answers

My child complains that it hurts to chew or swallow Candidiasis, also called thrush, and herpes are common in infants and children with HIV. They can be treated with medicine, so tell your doctor if your child seems to have a sore mouth or throat. Be sure to take your child to the dentist regularly, and gently brush teeth and clean gums after each meal. See Nutrition Tip Sheet #1. In general, hot foods and carbonated drinks can irritate tender tissues in the mouth and throat. Foods that are soft, cool or room temperature and are simply prepared with little or no seasoning are tolerated better.

Try these suggestions:

Offer popsicles, ice cream, frozen yogurt, sherbet and frozen fruit to help numb the mouth and reduce pain Offer soft, mildly flavored foods like mashed potatoes, scrambled eggs, applesauce, bananas, pears, macaroni and cheese, pasta, rice, soups, cooked cereal, puddings, and custard Offer apple juice or fruit nectars Try drinking liquids through a straw Cut foods into small pieces Add butter, thin gravies, and sauces to make foods easier to swallow Blenderize meats and vegetables in extra liquid AVOID: tomatoes, citrus fruit and their juices, spicy foods, rough or hard to chew foods like crackers, peanut butter, and hard cereals

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Quick Nutrition Screen: Question #12

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My child does not take a vitamin Infants and children with HIV have increased needs for certain vitamins and minerals, but the best amount to give is not yet known. Always speak to your doctor and/or Registered Dietitian or other nutrition professional before giving your child a vitamin or mineral supplement.

Infants
Vitamins and minerals are added to infant formulas; if your infant is drinking about 24 to 28 ounces of formula a day, he/she is probably getting enough vitamins and minerals. If your infant is drinking less than 24 ounces of formula, then a liquid multivitamin is generally recommended. Liquid vitamins usually do not contain minerals. When your infant is old enough to chew well, it is a good time to switch to the chewable tablet containing minerals.

Children
A multi-vitamin with minerals in liquid or pill form is recommended for all children over 1 year of age with HIV. The supplement should provide no more than 100% of the Recommended Dietary Intake (RDI) or Recommended Dietary Allowance (RDA). Brand names of some children's chewable vitamin and mineral supplements that will meet your child's needs include: Bug's Bunny with Minerals, Flinstones Complete and Centrum for Kids Complete. Generic and store brands may also be good. Compare the label with one of the above to make sure it contains all of the same vitamins and minerals, in the same amounts. You will notice that the label will also tell you if it provides 100% of the RDA or RDI.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #13

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My child takes extra vitamins or herbs Children with HIV infection have increased needs for vitamins and minerals. A normal diet may not provide adequate amounts of key nutrients, either because of nutritional losses with vomiting or diarrhea or because of increased needs to fight infection. It is recommended that children with HIV/AIDS take a daily pediatric multiple vitamin and mineral supplement which provides 100% of the Recommended Dietary Allowances (RDA) for the B vitamins, Vitamins A, D, E, C, folic acid, iron, selenium and zinc. Children younger than 2 years old should be given a liquid vitamin/mineral preparation. Children older than 2 years old may be given a chewable tablet. Herbal remedies are not recommended for children. Safe dosages for children have not been determined. Dosages of key ingredients may vary from product to product. Plus, how herbs interact with medications is not known. The small body size of children makes it easy to mistakenly give toxic dosages. If you are considering offering your child an herbal remedy, discuss this with your child's pediatrician first.

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Quick Nutrition Screen: Question #14

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Our family has difficulty getting enough food Many families have difficulty paying bills and buying enough food. In the USA we are fortunate because we have many government sponsored and privately sponsored food programs. Some of those programs include the Special Supplemental Food Program for Women, Infants, and Children (WIC), Food Stamps, School lunch and breakfast, soup kitchens, food pantries and home delivered meal programs. Your Registered Dietician or other health professional, Nutritionist, social worker, or case manager can help you enroll in these programs if you are eligible. Unfortunately, even with these food programs, many families still have difficulty keeping enough food in the house all the time. Moreover, some of us may not be enrolled in food programs but still want to save money. Some tips for managing your familys meals on a limited income are below.

Tips for managing your familys meals on a limited income:

Buy store brand items. They are usually less expensive than brand name foods. Store brand frozen foods are especially economical. Try to buy the weeks specials. It may be possible to save as much as 40 50 cents a pound on meat if you buy it on special. However, watch bargains. If an item is featured make sure it is actually priced lower than usual and is really the least expensive option. Also watch the expiration date, and don't buy meat that is outdated. You may find markdowns on slightly old fruits and vegetables on Saturdays. If a head of lettuce or escarole has been trimmed down so that the dark outer leaves are gone - it is too old. Bagged apples and oranges are usually less expensive, but be sure to check them for freshness. See Nutrition Tip Sheet #7.

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Buy fresh produce in season. To get the most value for your dollar, it is important to learn how to cook basic foods. Next to eating out, the most expensive thing is buying convenience foods. In general, the more processed the food is, the more expensive it is. For example, it is less expensive to make mashed potatoes from whole potatoes than to buy instant mashed potatoes. If you buy frozen vegetables, it is more economical to buy the packages without seasoning or sauces built in and then add your own. Spices can be expensive, but they will save you money when you buy foods without seasonings and add your own. Buy a spice once or twice a month to build up a good selection. Fresh herbs such as cilantro and parsley may be less expensive, but wont last as long. To lower your food budget you may want to shop for less expensive foods to substitute for the ones you currently buy. For example beef might be replaced with turkey or beans. If prices are up on rice or grits, substitute with pasta or bread. If you really enjoy eating meat, learn what good pieces of meat look like. There are many cuts between sirloin steak and hamburger. Bone-in chuck steaks cost about the same as hamburger and make great broiled steaks. You can also serve meat with rice or vegetables so that the meat portion size can be smaller. Learn to read labels. Ingredients are listed in order of quantity. Learn terms and standards specified by the USDA. For example, fruit punch is not 100% fruit juice, luncheon meats have more meat than meat loaves such as chicken loaf, and processed cheese has less cheese because fillers are used. Pay attention to packaging, for example, sugar in the bag is cheaper than in the box, and spices in fancy boxes are more costly. Use unit pricing - the cost per ounce or per unit of the product - to compare the cost of similar products. Unit prices can be found on the label or the shelf below the product.

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #15

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We do not have a place to cook or to keep our foods cold Not having a place to cook or store food can present a real problem to you and your childs health. Some families may have access to meals in a group home or shelter, but the group home may only offer three meals, which may not be enough for a growing child. Other families may not have access to meals or meal preparing facilities at all. See below for more tips on foods that dont require refrigeration and/or a stove.

Foods that dont require stove, oven, or refrigeration (unless there are leftovers):
Peanut

butter and jelly* sandwiches Raisins, dates, figs and other dried fruits Canned fruit or applesauce* Peanuts, cashews, almonds, Brazil nuts and other nuts Pumpkin and sunflower seeds Crackers such as saltines, Ritz, graham crackers Bread, rice cakes, pretzels, bread sticks, granola, rolls, bagels

Trail mix, granola bars, angel food cake Canned tuna,* chicken,* ham,* and beans* Bananas, apples, pears, and oranges Dry ready-to-eat cereals, instant hot cereal made with hot tap water Dried milk, canned milk,* Parmalat* (milk in a box) Liquid supplements such as Pediasure,* Nutren Jr.,* Peptamin Jr.,* and Kindercal*

*Buy the smallest amount that you can consume at one meal, because leftovers do need refrigeration. Consider using an ice chest for leftovers, where ice is replaced as needed.

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Nutrition Guidance for Positive Children

Requires stove/hot plate/microwave but not refrigeration (unless there are leftovers):
Canned creamed corn, spaghetti, stews, chili Canned soups Canned beans Canned yams Boxed macaroni and cheese mix Pasta Instant grits, oatmeal, cream of wheat Instant mashed potatoes, baked potatoes Cocoa Mix Popcorn

Requires refrigeration once opened, but no stove/hot plate/ microwave:

Juices - V-8, orange, apple, cranberry, grape Some fresh fruits and vegetables Milk, yogurt, cheese, cottage cheese, prepared puddings and sour cream Lunch meats

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Nutrition Guidance for Positive Children

Quick Nutrition Screen: Question #16

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I often don't feel like eating, food shopping or cooking It is understandable that if you are ill yourself, you may not always have the energy to shop or prepare a meal for your child. It is especially important that you let health care providers, friends, and family know about this so that you can get some extra support and help. Your nutritionist, social worker, or case manager may be able to help you locate a free meal delivery service if you are eligible. It is important to plan ahead for a time when you may not want to make that trip to the store, or prepare a complicated meal. It helps to have some foods on hand at home. There are certain foods which can help you put a healthy meal together fast.

The following foods can help make food preparation easier:

Canned meats and canned ham are fully cooked and ready for sandwiches or can be added to soups or salads. Canned tuna or salmon can be mixed with bread crumbs and egg to make patties or fish burgers. Canned beef stews, canned spaghetti, and canned soups. You can also increase the nutritional value by adding cooked meat or vegetables. Canned pork and beans, canned baked beans, canned chili beans. Canned beans are faster to make than dried beans are. Try heating these up and putting on a baked potato. Top with cheese. You can also try mashing the beans and spreading on crackers, in a sandwich, or rolled in a tortilla. Canned chili - add extra beans or meat, try putting on a baked potato or over a salad, top with grated cheese, tortilla chips, and sour cream. Frozen pizza - add extra cheese and/or vegetables if you want. Boxes of macaroni and cheese, boxed rice mix and noodle dishes, and boxed scalloped potatoes - add grated cheese, and/or canned peas, or tuna, chopped cooked meat or chicken. Cereal hot or cold - add extra fruit and nuts. Hot cocoa mix - mix with milk versus water. Peanut butter - can be spread on bread, or put on fruit or vegetables. Cottage cheese, yogurt, cheese slices, pudding, ice cream.
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Hard boiled eggs - boil a dozen eggs at a time and store them in a covered container for a week in the refrigerator. Eat them plain as a snack or at mealtime. You can also chop them up and add to cream soup, salad, or make egg salad, or deviled eggs. Hot dogs and sandwich meats. Sip high-calorie drinks such as shakes and supplements throughout the day. Make clean up easier by using disposable cooking pans, plates, and cups. Keep take-out food menus and telephone numbers on hand. Accept help from friends and family. On days when you are feeling well buy, prepare, and freeze extra food so you'll have it readily available for later.

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Quick Nutrition Screen: Question #17

More information about your YES answers

My child has high blood cholesterol Currently, there are no specific guidelines for changing the diet when a child with HIV infection has high blood cholesterol. There has been a trend for lipid (fat) levels to rise, especially when highly active antiretroviral therapy (HAART) is used, but it has not been shown that dietary changes will lower lipid levels. However, it is wise to begin early to help your child develop good eating habits for long-term health and the prevention of other diseases, such as heart disease, later in life. Be sure to provide enough calories and nutrients for optimal growth and be sure not to limit too many foods. For example, if you decide to limit your childs egg consumption to three eggs per week, you should find a heart healthy alternative such as oatmeal, pancakes, waffles, or cereal with low-fat milk, to replace the eggs. Because this is such a critical period of growth, be sure to work with a Registered Dietitian or other nutrition professional.

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The following is a list of foods to decrease (but not eliminate), and foods to choose instead:
Foods to Limit: Whole eggs, especially the yolk Alternative Choices: White part of egg, cholesterol-free egg substitute Lean meats such as: Lean ground beef, chicken, turkey Pork - tenderloin, leg or shoulder Poultry without skin, baked/broiled Turkey bacon, soy bacon, trimmed veal, Low-fat chicken or turkey hot dogs Turkey, lean ham or lean beef lunch meats Pasta, macaroni Homemade baked goods using vegetable oil and skim or 1% milk Corn tortillas Fresh fruits and vegetables Cooked beans and peas

High fat meats such as: Regular ground beef, canned beef Pork - spareribs, blade rolls, poultry with skin, fried chicken, bacon, sausage, beef or pork hot dogs, bologna, salami, organ meatsliver, kidney Egg noodles Commercial baked pastries, croissants, cookies Flour tortillas

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Quick Nutrition Screen: Question #18

More information about your YES answers

My child has high blood pressure High blood pressure in children is relatively uncommon, but there are many things that could cause high blood pressure in children with HIV infection. Some causes might be kidney disease, heart disease, medications, and maybe diet. Your health care provider will investigate the cause of your child's high blood pressure if there are three high readings. It would be wise to lower the salt content of your childs diet in any case. Talk with your Registered Dietitian/ Nutritionist or health care provider. Try to use less salt in meal preparation and do not sprinkle food with salt.

Foods that are high in sodium and may need to be limited:

Foods with visible salt: salted nuts, potato chips, tortilla chips, salted popcorn, crackers, and pretzels Processed foods: canned foods like soup, vegetables, chili, canned beans, tomato sauce, and pizza sauce Convenience foods: frozen meals, boxed macaroni and cheese, rice or noodle mixes, boxed stuffing, Ramen noodles, instant oatmeal Baked goods and prepared mixes: biscuits, cornbread, muffins, pan cakes, waffles, cakes Canned or cured meats: ham, bacon, salt pork, sausage, Bologna, salami, hot dogs, sardines Dairy products: cheese, processed cheese spread, buttermilk, cottage cheese Seasonings: salt, seasoned salt, onion salt, garlic salt, soy sauce, barbecue sauce, bouillon cubes Other salty items: olives, pickles, relish, capers, prepared mustard, ketchup, sauerkraut

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Quick Nutrition Screen: Question #19

More information about your YES answers

I have a hard time getting my child to take the medicines Children can have a particularly hard time taking medicines. The large number of medications, large size of some of the pills, horrible tastes of many liquid medications, and additional diet changes to accommodate the medications all make it hard for a child.

The following suggestions may make it easier to give medications:

Be honest with your child. Talk with him or her before offering new medicines or changing his medicine schedule. Whenever possible, give your child some control over how to take medicines. For example, ask if he or she would like to take the medicine before or after a favorite story or television show. Discuss scheduling of the medication with your child's physician, pharmacist or nurse in order to group medicines that can be taken together and decrease the number of times the child's day is interrupted. If allowed or possible, refrigerate liquid medications in order to decrease the smell and taste sensation. Also, taste buds can be dulled by chewing ice or Popsicles before taking medication. Use thick foods to coat the mouth. A small amount of peanut butter or pudding may coat the mouth and decrease the affect of a bad tasting liquid medication. Check with your child's physician to ensure that the food offered can be taken with the medication. Use chasers. A strongly sweet or sour food offered with or after the medication may quickly erase a bad taste in the mouth. Check with your child's physician to ensure that the chaser can be given safely with the medicine. Some medications require that your child drink extra fluid during the day. Offer extra fluids after, rather than before meals in order to ensure a healthy appetite for nutritious foods. Use child friendly cups, sports bottles, or fun shaped straws to encourage more drinking.

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Compatible medicines may be mixed in with a soft food that your child likes (e.g. ice cream, applesauce or chocolate milk). Be careful not to use your child's favorite food or basic important foods, like chicken or eggs. The child might associate the food with medicine and refuse that particular food. For older children, switch to the tablet or capsule form of the medication instead of the liquid form. Younger children may be taught to take pills. Discuss how to do this safely with your child's nurse or physician. Use non-food rewards to encourage medication taking: praise, stickers, etc.

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Quick Nutrition Screen: Question #20

More information about your YES answers

My child does not show interest in active play If your child does not seem to have any energy or interest in play, contact your physician. The low energy level may be a sign of illness, medication effect, or depression that needs to be treated. It could be boredom and that needs attention, too.

If no illness, medication effect or depression are found, the following ideas may spark your child's interest in play:
Be sure your child is receiving a good diet. Not getting enough calories and key nutrients may cause him or her to feel tired. Offer balanced meals and snacks and keep track of what and how much your child eats for a few days. Ask your Registered Dietitian or other health professional to evaluate your child's diet. Be sure your child is getting enough rest. Not enough sleep may cause your child to lack energy during the day. Substitute social games for television. Invite your child and a friend to go with you on a neighborhood safari. Count the number of different bugs, birds, or leaf shapes you find. Play a board game with your child. Help your child build physical skills. Your child may be self-conscious about his or her lack of skills needed to play certain games well. Play with your child and have fun. Take your child to a neighborhood park where he or she can practice running, throwing, catching, etc. Enlist the help of friends and family members in arranging regular physical activity for your child. If your child shows an interest in team sports or dance, sign him or her up. Speak with the director to find out if the program is supportive of children with varied skill and energy levels.

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Nutrition Tip Sheet #1 Dental Care
Most young children eat frequently, and regular tooth brushing is needed to keep teeth and gums healthy. Frequent and thorough brushing of teeth keeps bacteria from settling on teeth and gums and causing decay. Follow these tips for healthy teeth and gums: See the dentist every 6 months for a check-up. Choose a soft toothbrush and have your child brush 3 to 4 times each day. If gums are sensitive, clean the child's teeth with a q-tip or sponge mouth swab. In older children with sore mouth and gums, rinse mouth with a baking soda and warm water mixture. Take care to not swallow this! Baking soda mixture: 4 ounces warm water 1/2 to 1 teaspoon of baking soda Sticky foods like caramels should be avoided unless the teeth are brushed shortly after sticky foods are consumed. Use a fluoridated toothpaste and drink fluoridated water, or give a fluoride supplement prescribed by your doctor. If your child uses mouthwash, buy one without alcohol.

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Nutrition Guidance for Positive Children

Nutrition Tip Sheet #2 Feeding Your Sick Child
Nausea and Vomiting:
Call your doctor to help identify the cause of nausea and vomiting if possible. Treat as suggested. Position the child in a more upright position (raised head of bed, using pillows for propping with older children). During waking hours offer small meals every 2 hours, and fluids every 1-2 hours. Provide simply prepared foods, like plain rice or pasta, potatoes, pretzels, cooked or canned fruit and vegetables, baked chicken or turkey, sherbet, angel food cake. If possible, adjust timing of nausea-causing medications to one-half hour before meals. Try dry plain foods like toast, crackers, dry cereal. Serve liquid after meals, as liquids can increase feeling of fullness; try cool or chilled liquids. AVOID: high fat or greasy foods, or foods with strong flavors or spices. AVOID: feeding the child in a stuffy, over-warm room, or one with strong cooking or food odors. Try giving foods that are cold or room temperature rather than hot foods. For example, a cold turkey sandwich rather than hot turkey with gravy.

Diarrhea:
Identify cause of diarrhea if possible and treat as indicated. During waking hours, offer fluids every 1-2 hours - especially diluted fruit juices (half water and half juice), sports drinks, or Pedialyte; drinking liquids is very important to prevent dehydration. If dairy products seem to make diarrhea worse, avoid them until your child is better (If lactose intolerance is suspected, see Quick Nutrition Screen Question #9). If high fat foods seem to make diarrhea worse, offer low fat foods and ask your doctor or Registered Dietitian or other nutrition professional about using a supplement with MCT oil. During waking hours, offer small meals every 2 hours. Try plain rice or pasta, cooked cereal, soft cooked eggs, ripe bananas, canned fruit, plain baked or boiled lean chicken or turkey, white bread or toast.

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Eat foods with sodium and potassium, to replace minerals lost in diarrhea. Examples of sodium and potassium rich foods are: bouillon, broth, bananas, peach and apricot nectar, and potatoes. If your child almost always has diarrhea, try to increase soluble fiber (like fruit and vegetables without skins or seeds, rice, oatmeal, and potatoes). AVOID: greasy, fried, high fat foods, spicy foods, chocolate, caffeinecontaining soft drinks.

Fever:
In general, a fever increases the child's fluid and energy needs. To prevent dehydration, getting enough fluid intake is very important. Offer sips of fluid almost hourly each hour your child is awake. Offer diluted fruit juice (half water and half juice) or drinks rather than water. Offer meat or vegetable broth. Use oral rehydration products, such as Pedialyte or Ricelyte, as recommended by your health care provider. Offer soft foods as tolerated.

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Nutrition Tip Sheet #3 Constipation
Constipation in childhood is not uncommon. It can be caused by not eating enough high fiber foods, not drinking enough liquid, and/or not enough physical activity. It can also be a side effect of medication.

Fluids: Fluid needs for children will depend upon how much he or she weighs. In general, the fluid needs of children are higher per pound than adults. Their fluid needs per pound of body weight gradually decrease as the child gains more weight.
Weight of child 20 pounds 25 pounds 30 pounds 35 pounds 40 pounds 45-50 pounds 51-60 pounds 61-70 pounds 71-80 pounds 81-99 pounds 100-140 pounds Needs to drink per day 30 ounces - 3 3/4 cups 35 ounces - 4 1/3 cups 40 ounces - 5 cups Getting Enough 43 ounces - 5 1/3 cups Physical Activity: 46 ounces - 5 3/4 cups See Nutrition Screen Ques50 ounces - 6 1/4 cups tion #20 for ideas to increase 55 ounces - 6 1/4 cups your child's daily physical 57 ounces - 7 1/4 cups activity level. 58 ounces - 7 1/4 cups 60 ounces - 7 1/2 cups 65-70 ounces - 8 1/4 - 8 3/4 cups

If a child is over 120 pounds, the guideline for fluid in the same as in adults about 1/2 ounce of water per pound of body weight. This may equal 8-10 cups of fluid per day. Fluid needs are met by drinking enough water, milk, juice, soups, and other liquids each day.

High Fiber Foods: For normal bowel "function", a child needs a balance of fiber from fruit and vegetables and whole grains. A general recommendation is to provide 5 servings of fruit and/or vegetables per day, as well as 2-3 servings of foods made from whole grains. Read labels of bread and cereal products for fiber content, look for foods that contain at least 2-3 grams of fiber per serving Use breads made from 100% whole wheat flour Use nuts and seeds in cooking Add wheat or oat bran to baked foods Eat legumes (such as pinto, kidney, garbanzo beans, or peas)
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Nutrition Tip Sheet #4 Snacks & High Calorie Suggestions
Most children cannot meet their nutritional needs in just 3 meals a day. Three meals and 3 snacks (or 6 mini-meals) daily are best to meet the growing child's needs.

Snack ideas for toddlers: Peanut butter on graham crackers, apples or celery Yogurt and fruit Cream cheese on crackers with sliced fruit Frozen juice bars Mini pizza - French bread or English muffin half, topped with tomato sauce and shredded cheese Pudding or custard Cottage cheese and fruit Snack ideas for school age children: "Smoothies" - blend 1/2 cup fresh or frozen fruit with 1/2 cup ice cream or yogurt Raw vegetables (carrots, broccoli, cauliflower) dipped into ranch dressing Melted cheese on tortilla Trail mix (nuts, seeds, and dried fruit) Popcorn with melted butter, sprinkled with parmesan cheese High calorie ideas: Offer high calorie (or energy-dense) foods - pudding, custard, whole milk or half and half, macaroni and cheese, dried fruit, cooked cereal made with whole milk Melt butter or margarine onto foods Add sweetened condensed milk or evaporated milk to puddings, milk shakes and baked foods Offer milkshakes made with whole milk, fresh or frozen fruit, ice cream Add "instant breakfast" powder to milk Add powdered milk to puddings, mashed potatoes, soups, and cooked cereals; it can also be added to whole milk (1 Tbsp. has 33 calories and 3 grams protein) Try commercial high calorie drinks like Nutren Junior, Pediasure, Kindercal, Scandishake added to foods, mix with ice cream, make popsicles. Often children prefer these commercial drinks chilled.
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Nutrition Tip Sheet #5 Making Mealtime Less Stressful
Mealtime can be stressful for any family with young children.

For developing good eating attitudes and habits: Sit down at the table and enjoy eating meals and snacks with your child Provide pleasant, safe, eating environment, free from distractions (like TV) Serve meals and snacks at consistent times Plan a quiet time for 10-15 minutes before the meal Include child in food preparation whenever possible; many children enjoy helping! Use child-sized plates, cups, spoons and forks Present foods that are appealing - include a variety of food colors and textures in the meal Develop a regular meal and snack time routine For managing "the picky eater", the caretaker's role is to: Provide a variety of nutritious food Routinely offer them at regular times Set a good example by eating a variety of nutritious foods yourself Allow the child to choose to eat or not eat foods offered Provide favorite foods for times when appetite is poor Offer very small portions and let your child ask for more Avoid any fights over foods and eating/not eating
It is important to find a balance between setting limits and spoiling your child. Children with HIV are living long healthy lives. Over-indulging them with food is not helpful in the long run as poor eating habits develop early and they are more difficult to correct later.

Special considerations for the toddler: Offer bite-sized foods that are easy for the child to feed him/herself Soft, relatively easy to chew foods Serve meals that contain one of the child's favorite foods along with new foods AVOID: foods which may cause choking - hot dogs, chunks of meat, grapes, nuts, hard candies, popcorn, raw carrots For all ages: Offer a variety of foods of different textures, tastes, and colors Make sure to include breakfast as part of the daily routine
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Nutrition Tip Sheet #6 Giving Medications
Special Nutrition-Related Instructions for Available Antiretroviral Drugs: Nucleoside Analogue Reverse Transcriptase Inhibitors Didanosine (ddI, Videx): ddI formulation contains buffering agents or antacids. Food decreases absorption; give your child ddI on an empty stomach (1 hour before or 2 hours after a meal). Further evaluation in children regarding administration with meals is under study. For oral solution: shake well and keep refrigerated. When administering chewable tablets, at least two tablets should be administered to ensure adequate buffering capacity (e.g. if the child's dose is 50 mg, administer two 25-mg tablets and not one 50-mg tablet). Lamivudine (3TC, Epivir): Can be administered with food. For oral solution: store at room temperature. Stavudine (d4T, Zerit): Can be administered with food. For oral solution: shake well and keep refrigerated. Zalcitabine (ddC, Hivid): Administer on an empty stomach (1 hour before or 2 hours after a meal). Zidovudine (AZT, Retrovir): Can be administered with food (although the manufacturer recommends administration 30 minutes before or 1 hour after a meal). Non-nucleoside Reverse Transcriptase Inhibitors Delavirdine (DLV, Rescriptor): Can be administered with food. Should be taken 1 hour before or 1 hour after ddI or antacids. Tablets can be dissolved in water and the resulting dispersion taken right away.
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Nutrition Guidance for Positive Children

Nevirapine (NVP, Viramune): Can be administered with food. For investigational suspension: Must be shaken well. Store at room temperature. Protease Inhibitors Indinavir (Crixivan): Give indinavir on an empty stomach 1 hour before or 2 hours after a meal. It can be taken with a light low fat snack. See approved food list elsewhere in this manual. Adequate hydration required to minimize risk of kidney stones (at least 48 ounces of fluid daily in adult patients). If co-administered with ddI, at least 1 hour apart on an empty stomach. Avoid grapefruit juice. It interferes with the amount of drug that gets into the blood. Nelfinavir (Viracept): Administer with meal or snack If co-administered with ddI, nelfinavir should be administered 2 hours before or 1 hour after ddI. For oral solution: powder may be mixed with water, milk, pudding, ice cream, or formula (for up to 6 hours). Do not mix with any acidic food or juice because of resulting poor taste. Tablets readily dissolve in water and produce a dispersion that can be mixed with milk or chocolate milk; tablets also can be crushed and administered with pudding. Ritonavir (Norvir): Administration with food increases absorption. If ritonavir is prescribed with ddI, there should be 2 hours between taking each of the drugs. Tablets should be kept refrigerated and stored in original container; can be kept at room temperature if used within 30 days. In the summer or if you live in warm climates, take care to keep tablets cool and out of the sun and heat. To minimize nausea, therapy should be initiated at a low dose and increased to full dose over 5 days as tolerated.

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Nutrition Guidance for Positive Children

The taste of the oral solution can be hard to take. Tips for taking the oral solution: A) Mix oral solution with milk, chocolate milk, or vanilla or chocolate pudding or ice cream; B) Dull the taste buds before administration by chewing ice, giving Popsicles or spoonfuls of partially frozen orange or grape juice concentrates; C) Coat the mouth by giving peanut butter to eat before the dose; or give strong-tasting foods such as maple syrup, cheese, or strongflavored chewing gum immediately after dose. Saquinavir (Fortovase): Administer within 2 hours after a full meal to increase absorption. Grapefruit juice increases the amount of saquinavir that gets into the blood. Amprenavir (APV) (Agenerase): Amprenavir is available in an oral solution and in capsules. Amprenavir should not be used in children less than 4 years of age. The liquid preparation contains propylene glycol, which is not proper for young children. Neither the capsule form nor the oral solution has been approved for use in children less than 4 years of age. Amprenavir can be taken with or without food, but should not be given with a high fat meal. A high fat meal is defined as a meal with 67 grams of fat or more. For example, a Burger King meal of one order of medium sized French fries, a bacon double cheeseburger and a medium vanilla shake contains 69 grams of fat. Children and adults taking antacids or ddI should take amprenavir at least 1 hour before or after antacid or ddI use. Most common side effects of amprenavir are: nausea, abdominal pain, headache, metallic taste, dizziness and asymptotic hyperbiliruvinemia (10%) Amprenavir contains a substantial amount of vitamin E. 1 mL oral solution = 46 IU vitamin E 150-mg strength capsule = 109 IU vitamin E Children and adults taking amprenavir should be advised not to take supplemental vitamin E. A regular multiple vitamin-mineral supplement containing 100% of the RDA or DVI for vitamin E is usually okay. Discuss supplements with your doctor. High vitamin E doses may exacerbate the blood coagulation defect of vitamin K deficiency cased by anticoagulant therapy or malabsorption.

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Nutrition Guidance for Positive Children

Possible vitamin E toxicities include thrombophlebitis, pulmonary embolism, hypertension, severe fatigue, gastrointestinal symptoms, creatinuria with prolonged use, gynecomastia in men and women, breast tumors. Resources for more information about amprenavir: 1) Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Convened by the National Pediatric and Family HIV Resource Center (NPHRC), the Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH). December 14, 2001. Available at www.hivatis.org. 2) GlaxoWellcome, Vertex: Agenerase product information, April 1999.

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Nutrition Tip Sheet #7 Avoiding Foodborne Illness
Why is it important to be careful about food sanitation? Public health and food safety experts estimate that millions of illnesses can be traced to contaminated food. Harmful microorganisms such as bacteria or germs are present everywhere, and food is a good place for these germs to live and reproduce. Children, the elderly and people who have compromised immune systems are the most likely to become sick from spoiled food because they cannot fight off the germs. Food poisoning can strike anywhere from two hours to two days after eating. Some toxins in fish can work within minutes, while botulism could take up to a week. Foodborne illness can be minimized or prevented if proper precautions are taken.

Safe Food Handling Tips:

Wash hands with soap before, during, and after handling food. Always wash your hands well after going to the bathroom or diapering your baby. Teach children to wash their hands, too. Teach children to wash hands each time they handle food and each time they use the bathroom, too. Make a game of hand washing. For example, each time scrub hands singing a different nursery rhyme. Wash and sanitize all work surfaces, cutting boards, knives, and utensils. Use a dishwasher with water temperature set on high if available. Wash your hands again after touching any raw meat, raw fish, raw chicken, raw turkey, raw pork, or raw eggs. Never let any raw juices from these foods touch any other food. Do not serve or eat raw fish like sushi, oysters, or clams. Do not serve or eat raw eggs, and cook all foods made with raw eggs, such as cookie dough, bread, or cake batter before eating. Do not add raw eggs to drinks such as malts or shakes. Freeze foods at 0 degrees Fahrenheit or below. Refrigerate foods at 40 degrees Fahrenheit or below. Buy a freezer/refrigerator thermometer at the supermarket and check it regularly. Thaw or defrost meats, chicken, and turkey in your refrigerator overnight or in a microwave oven. If these foods are thawed or defrosted in the microwave, cook them right away. Never thaw or defrost meats on the counter at room temperature.
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Refrigerating and freezing food can slow down growing bacteria but not kill them. Once frozen foods thaw or defrost to room temperature, bacteria can grow again. Bacteria multiply the fastest between the temperatures 40 degrees Fahrenheit and 140 degrees Fahrenheit. Bacteria die at high temperatures when food is well cooked through to the middle. Use a meat thermometer to check the internal (inside) temperature of food. Beef should be cooked to an internal temperature of at least 170 degrees Fahrenheit. Lamb, chicken, and turkey should be cooked to an internal temperature of at least to 180 degrees Fahrenheit. Foods cooked in a microwave may heat unevenly. Be sure to follow the microwave directions, and check internal food temperatures in a variety of areas. Do not allow foods to sit at room temperature for more than 2 hours. Cool leftovers in the refrigerator or freezer. Large batches of cooked food should be divided into small portions in shallow containers then put into the refrigerator or freezer so food can cool faster. Check with your local Environmental Protection Agency or water source agency for information about germs that may be in tap water. Teach children about "unsafe" food and water. Teach them to politely say "no thank you" to when they are offered "unsafe" food or water. For more information on food and water safety see References (Section 10) .

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For the Clinician #1
General Monitoring
A baseline nutritional assessment should be completed as soon after a child is identified as HIV-infected as possible in order to prevent malnutrition and growth failure. Nutritional reassessment by the Registered Dietitian or other nutrition professional should be done at least every 6 months. More frequent evaluation and intervention are warranted when clinical symptoms or growth abnormalities are present. (1) A complete nutritional assessment includes weight, height, head circumference (to 36 months of age), and body composition assessment. Body composition can be evaluated using skinfold measurements (eg. tricep and subscapular) or bioelectrical impedence. Weight and height growth velocities should be evaluated using the National Center for Health Statistics growth charts and/or the incremental growth charts. Deceleration of the growth velocities indicates the need to evaluate for nutritional intervention. (1)(2)(3) The biochemical markers that should be a standard component of evaluation are albumin, prealbumin, hemoglobin, hematocrit, cholesterol and triglycerides. If micronutrient deficiencies are suspected, specific serum assays should be assessed. (2)(3) The childs typical intake should be assessed using 24-hour recall, food record, and/or food frequency questionnaire. Signs of poor intake or excessive losses through diarrhea or vomiting are important to investigate and appropriate nutrition intervention should be incorporated in the overall nutritional care plan. Refer to Children/Adolescent HIV/AIDS Medical Nutrition Protocol (3) and Nutrition Referral Criteria for Pediatrics (under 18 years) with HIV/AIDS (4), both located in Algorithms (Section 9). For more information, see References (Section 11).

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For the Clinician #2
Pediatric Enteral and Parenteral Nutrition
All parents want their children to enjoy a wide variety of nutritious foods and experience the special nurturing that takes place around the family table. There are times, however, when children with poor growth on formula or table food diets may require enteral nutrition (tube feedings) or parenteral nutrition (intravenous feedings). During these times every effort must be made to make these alternative feeding methods safe and effective while maintaining the child's positive relationship to food and the home feeding environment. Enteral Nutrition The prevention of malnutrition or wasting syndrome in children with HIV disease is a major concern. Children who fail to grow adequately on calorieenhanced oral diets, who have difficulty eating or who have difficulty absorbing and using nutrients may benefit from using enteral nutrition or tube feedings. Common problems specific to HIV disease which may require the use of tube feedings include growth failure, painful swallowing, infection, chronic diarrhea, vomiting or excessive spitting up, loss of appetite due to fever or chronic disease, brain damage, and stomach or intestinal problems. (Winter and Chang, 1996) Depression in children with HIV disease may be an under-recognized contributor to loss of appetite and poor growth. (Deatrick, et al., 1998) Tube feedings may provide a child's complete diet or they may be used as a supplement to a regular diet. The mildly malnourished child who is able to eat and absorb nutrients should not be tube fed unless major efforts to increase the nutritional content of formula or table foods have failed. Tube feedings may not be advised if the child is very malnourished or has severe vomiting or diarrhea. In these situations, intravenous nutrition or parenteral nutrition may be required. Often, however, it is possible to combine some amount of enteral nutrition with intravenous nutrition. When short-term use of the feeding tube is expected, placing the feeding tube into the nose is preferred. Long term use of nasal feeding tubes is not recommended because it may cause infection of nasal sinuses (Winter and Chang, 1996), and the child's changed appearance during nasal tube feedings may be a source of added distress for the child and family. Feeding tubes placed directly into the stomach or small intestine are more discrete and can easily be "hidden"
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under a child's regular clothing. These tubes, called gastrostomy tubes or jejunostomy tubes, are commonly used in children who will need to receive tube feedings for an extended period of time. The physician places the PEG (percutaneous endoscopically placed gastrostomy tube) in a rather simple procedure. Feeding schedules, amounts and rates for enteral feeds are based upon a careful assessment of the child's overall health, with particular attention to the child's ability to tolerate the feeding. Tube feedings may be either continuous or intermittent. Continuous feedings are given at slow rates over many hours. In bolus feedings a larger volume of liquid nutrition is given intermittently but over a short time. When first starting to tube feed a child the continuous method is better tolerated. Once the child has shown good toleration of continuous feeds at the full volume needed, a change may be made to intermittent or bolus feedings. Bolus feedings allow the child to have greater freedom of movement and independence since the feeding pump can be disconnected when not in use. There are many factors to consider when selecting a tube feeding nutritional product. It is important to consider the child's developmental status, nutritional status and overall health when selecting a nutritional product. (Lingard, 1993) If there is a history of food allergy or intolerance select a product which does not contain the offending agent. Additional product characteristics to be considered include nutrient composition, (type of carbohydrate, protein, fat, vitamins and minerals), nutrient density (number of calories, protein, etc. per volume) and osmolarity (the number of particles per volume). Products with a high osmolarity may cause diarrhea in some children and are seldom used when initiating tube feedings. Health care professionals and families need to monitor tube feedings for toleration and trouble shooting problems once enteral feedings have been initiated. The prevention of dehydration is quite important. Children can be fed safely and effectively by tube if proper attention is paid to the prevention of complications. Complications may include mechanical, infectious, nutritional, metabolic, gastrointestinal, and developmental problems. Reference sources are available to assist health care professionals and families with troubleshooting enteral feeding problems. (Lingard, 1993) In order to avoid contamination, it is important that caretakers use safe preparation techniques. These techniques include hand washing before initiating tube feedings, washing the top of the enteral product can before opening, using a clean punchtype can opener if a self-opener is not provided, cleaning feeding bags with
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Nutrition Guidance for Positive Children

warm, soapy water between usage and limiting formula hangs to 8 hours. Planning for home enteral support should include adequate training for parents, back-up caretakers and, as developmentally appropriate, the child. All caretakers must be given hands-on training in using all equipment, show skill in managing tube feedings, and receive support to express concerns and misgivings. All supplies must be delivered to the home prior to hospital discharge. Caretakers must also receive instruction on handling emergencies and be given telephone numbers for key personnel. Children and parents may have difficulty expressing their fears about tube feedings. A supportive environment should be created which encourages all family members to express their feelings and concerns. The nutrition plan should address all family concerns. Parenteral Nutrition (PPN/TPN) Parenteral nutrition is an accepted method for providing the nutrients children need to grow and thrive. Parenteral or intravenous nutrition is used when a child can not safely or adequately take in foods by mouth or tube feedings. Severe failure to thrive or weight loss greater than 10% is a general reason for the use of parenteral nutrition. (Cox, 1993) Other reasons for using parenteral nutrition in children with HIV-related conditions include: wasting syndrome, acute or chronic intractable diarrhea, inflammatory bowel disorders, severe brain disorders, heart muscle loss, liver failure and infection. Peripheral parenteral nutrition (PPN) involves the use of a peripheral vein and may be used when short-term (less than 5 days) nutritional therapy is anticipated.(Cox, 1993) Total peripheral nutrition (TPN) with a centrally placed catheter may be used when longer term intravenous nutritional care is expected. Although placing a central venous catheter in a child who is severely immunocompromised has some risks, children with HIV disease have safely received long term home and hospital based TPN. The TPN mixture is designed to provide adequate amounts of calories (as carbohydrates, protein and fat), protein, fat, vitamins, minerals, trace elements, electrolytes and fluid for the child's growth. Close monitoring of growth, fluid status, blood sugar, electrolytes, and other laboratory values are required. Guidelines for monitoring pediatric parenteral nutrition and handling metabolic complications are available. (Cox, 1993)

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Nutrition Guidance for Positive Children

Once the TPN regimen is stable and well tolerated, it is advisable to attempt cycling the TPN off for as many hours as possible, preferably during the day. Cycling allows the child to be free of the pump and related devices for part of the day. During the free hours the child is more able to play and participate in regular child activities. As soon and as much as possible, the child should be allowed to eat or re-start tube feeds. Infants and young children on prolonged TPN often lose interest in eating and lose feeding skills. (McCoy, 1991) If the child cannot eat, an occupational or speech therapist should be enlisted to create with the child and family a program to stimulate oral motor development. As in enteral feedings, children and their families are often distressed by changes in body image and freedom of movement associated with parenteral nutrition. Care should be taken to address these concerns. Clothing can be selected to disguise the feeding tubes. Portable feeding pumps and backpacks can be obtained. Feeding schedules can be re-arranged to meet the child or the familys lifestyle. Sometimes arranging a meeting between families considering TPN and families currently using TPN can provide mutually helpful peer support.

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Nutrition Guidance for Positive Children

For the Clinician #3
Guidlines for Children's Continuous Drip Tube Feedings:
Begin at a rate of 1-2 ml/kg/hour. Advance in increments of 0.5-1 ml/kg/hr every 8-24 hours as tolerated, until nutritional goal is achieved. Typical feeding rates for various age groups (Lingard, 1993):
Initial Rate (ml/hour) 3-10 Maximum Rate (ml/hour) 25-50

Age

Weight (kilogram & pounds) 3-10 kg 6.6-22 lbs. 10-20 22-44 lbs. 20-40 44-88 lbs. Above 40

Infant

Toddler / Preschool

10-20

60-70

School Age

20-40

80-100

Teenage

Above 88 lbs.

40-50

100-150

Signs and Symptoms of Dehydration in Children: Weight loss that is greater than 1% per day Increased thirst Dry oral membranes Increased urine specific gravity (more than 1.030) Decreased urine output (less than 1-2 mL/kg/hour) Increased Hct, serum Na, and BUN Fever Depressed anterior fontanel (scalp) in an infant Irritability

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Nutrition Guidance for Positive Children

Suggested Monitoring during Enteral Nutrition Support for Children: I. Growth
Parameter A. Calories, protein vitamins, minerals B. Weight for age C. Height for age D. Weight for height E. Head circumference (until age 3) F. Triceps skinfold G. Midarm muscle circumference Initial Week Daily Daily Initially Initially Initially Initially Initially At the If in the Outpatient Hospital Clinic Weekly Daily Weekly Weekly Weekly 2-4 weeks 2-4 weeks Monthly Monthly Monthly Monthly Monthly 1-3 months 1-3 months

II. Gastrointestinal
Parameter A. Abdominal girth B. Gastric residuals C. Vomiting D. Stools: Frequency/consistency Reducing substances Ova/parasites Daily Initially As needed Daily As needed As needed As needed As needed As needed Initial Week At least daily and as needed 2 hourly Daily In Hospital As needed 8 hourly Daily At Home As neeeded As needed Daily

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Nutrition Guidance for Positive Children

III. Mechanical
Parameter A. Tube position B. Nose Care C. Gastrostomy / jejunostomy site care Initial Week Initially 8 hourly As needed In Hospital 8 hourly 8 hourly As needed At Home 8 hourly 8 hourly As needed

IV. Metabolic
Parameter A. Electrolytes B. Glucose C. BUN / creatinine D. Visceral proteins E. Alk phos., trig., chol. F. Minerals (Ca, P, Mg) G. Vitamins, trace elements H. Hgb, Hct, MCV I. Fe, TIBC, retic. count J. Fluid intake/output K. Urine specific gravity Initial Week Daily until stable Daily until stable Initially Initially Initially Initially and daily As needed Initially Initally Daily Daily In Hospital Weekly Weekly Weekly 2-4 weeks As needed Weekly As needed PRN PRN Daily Weekly At Home Monthy if stable Monthly if stable Monthly if stable Monthly if stable 1-3 months Monthly if stable As needed to yearly 1-3 months 1-3 months Daily As needed

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Nutrition Guidance for Positive Children

For the Clinician #4
Complimentary Therapies: Vitamin/Mineral Supplementation and Herbal Remedy Usage with Children
The use of alternative or complementary medicine is increasing among the general United States population. Complementary nutritional therapies may include nutritional practices that enhance or substitute for foods taken by mouth. Some of these practices are proven to be safe and effective under proper supervision and are part of traditional standards of care. Non-standard nutritional practices are poorly documented in medical literature, may or may not be safe and are not proven to be effective. Two unproved and potentially unsafe practices are vitamin and mineral megadosing and use of herbal remedies. Although several studies have looked at complementary nutritional therapy usage among adult men and women living with HIV disease, (Vogl D, et al., 1998; Johnston et al., 1998) no published studies have looked at parent's use of complementary therapies with their children. Vitamin/Mineral Supplementation Megadosing or taking more than 200% of the Recommended Dietary Allowances for vitamins and minerals, unless prescribed and monitored by a physician, may be harmful to the child and is not recommended. Limited research has been done on vitamin and mineral insufficiencies in children with HIV disease. One study found that few HIV positive children had deficiencies in vitamins and minerals. (Henderson, 1997) Chronic diarrhea, a common problem in children with HIV disease, has been found to lead to lower levels of magnesium and zinc in infants. (Castillo-Duran et al, 1988; Rothbaum, 1982) Several nutrients play key roles in immune function, including vitamin A, vitamin E, B6, B-12, folate, selenium and zinc. (Liang et al., 1996) Increased intake of the antioxidants beta-carotene, vitamin E and vitamin C may also be helpful. (Mastroiacoro, et al., 1996) Studies of adults with HIV disease have shown decreased serum levels of many of these same nutrients. (Baum, 1997) Decreased iron stores are associated with certain anti-viral medications. For children living with HIV disease, practitioners routinely recommend a daily single dose supplement that provides 100% of the RDA for vitamins with additional iron and zinc. Close monitoring of the child's iron status should be
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Nutrition Guidance for Positive Children

done by health care providers to determine the need for additional iron supplementation. Blood tests to measure vitamin stores should be done on an as needed basis. Some parents give their children vitamin and mineral enhanced tonics in an effort to promote growth and improve immune function. While some of these tonics may be harmless, others are not designed for children and may contain harmful solvents (e.g. alcohol) or toxic doses of vitamins. Parents are advised not to give tonics to children unless approved by their pediatrician. Glutamine is an amino acid found in abundance in the body. It has many uses including energy, protein metabolism, and helping the body get rid of excess ammonia. Glutamine supplementation has been suggested to be helpful in preserving muscles in stressed patients, improving the body's immune system, and helping the intestines work properly. (Vanderhulst, et al., 1993; Hammarquist et al., 1989, Shabert and Wilmore, 1996) Glutamine has been used by both adult and pediatric patients with chronic diarrhea. No published guidelines exist for routine glutamine supplementation in children with HIV disease. Herbal Remedies and Children Herbal remedies are one form of complementary medicine. The use of herbs for medicinal purposes is commonplace among many social, ethnic and nationality groups. Food seasonings, such as ginger and garlic, may also be consumed for health purposes. When used in the amounts typically required to season foods, these herbs are regarded as safe for children as well as adults. Recent immigrants often have considerable experience using herbal remedies that are viewed as outside of mainstream medicine in the United States. No data exist on the use of herbal remedies in the pediatric HIV population. It is important for parents and medical providers to maintain open communication regarding the use of herbal remedies. Little is known about the safety and effectiveness of most herbal remedies. Some of them seem to enhance or prevent the body's use of other medications. Herbs that increase the potency of other medicines may cause severe illness. Herbs that interfere with the body's absorption of anti-viral medicines may allow the HIV virus to multiply.

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Nutrition Guidance for Positive Children

One popular herb, Echinacea, has been shown to increase viral replication. Another popular herb, St. John's Wort, has been shown to reduce drug levels of the protease inhibitor, indinavir. Because of how St. John's Wort is metabolized, the FDA has recommended that it not be used with any protease inhibitor or non-nucleoside reverse transcriptase inhibitor. A cause of concern with the use of herbs is our lack of information on the concentration of active ingredients in these products. Also, there is no agreement on appropriate dosages for children or adults. Children are at high risk because their bodies are small and their livers are not fully developed. Malnourished children are at even higher risk when exposed to harmful products. Families considering use of any complementary or herbal remedy for their child are encouraged to first discuss their plans with their medical provider. For more information see References (Section 11).

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