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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
JPEN J Parenter Enteral Nutr. Author manuscript; available in PMC 2012 June 3.
Published in final edited form as:
PMCID: PMC3366266

A.S.P.E.N. Clinical Guidelines: Nutrition Support of Children With Human Immunodeficiency Virus Infection

Nasim Sabery, MD, MPH1 and Christopher Duggan, MD, MPH2, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors


The clinical characteristics of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in children differ substantially from those in adults, and these differences are important to consider in providing both medical and nutrition care. Growth failure, wasting, and loss of active lean tissue are all associated with increased mortality and accelerated disease progression. The use of highly active antiretroviral therapy (HAART) has improved the prognosis and life span of children infected with HIV (HIV+) and has reduced rates of wasting. However, the emergence of HIV-associated lipodystrophy (HIVLD) has emphasized the extensive nutrition and metabolic manifestations of HIV infection. Maintaining the nutrition status of the HIV+ child is therefore crucial for optimal health outcomes.


The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is an organization comprised of healthcare professionals representing the disciplines of medicine, nursing, pharmacy, dietetics, and nutrition science. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of nutrition support therapy. A.S.P.E.N. vigorously works to support quality patient care, education, and research in the fields of nutrition and metabolic support in all healthcare settings. These clinical guidelines were developed under the guidance of the A.S.P.E.N. Board of Directors. Promotion of safe and effective patient care by nutrition support practitioners is a critical role of the A.S.P.E.N. organization. The A.S.P.E.N. Board of Directors has been publishing clinical guidelines since 1986.13 Starting in 2007, A.S.P.E.N. has revised these clinical guidelines on an ongoing basis, reviewing about 20% of the chapters each year in order to keep them as current as possible.

These A.S.P.E.N. Clinical Guidelines are based upon general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, the professional judgment of the attending health professional is the primary component of quality medical care. Because guidelines cannot account for every variation in circumstances, practitioners must always exercise professional judgment in their application. These Clinical Guidelines are intended to supplement but not replace professional training and judgment.

These clinical guidelines were created in accordance with Institute of Medicine recommendations as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.”4 These clinical guidelines are for use by healthcare professionals who provide nutrition support services and offer clinical advice for managing adult and pediatric (including adolescent) patients in inpatient and outpatient (ambulatory, home, and specialized care) settings. The utility of the clinical guidelines is attested to by the frequent citation of these documents in peer-reviewed publications and their frequent use by A.S.P.E.N. members and other healthcare professionals in clinical practice, academia, research, and industry. They guide professional clinical activities, they are helpful as educational tools, and they influence institutional practices and resource allocation.5

These clinical guidelines are formatted to promote the ability of the end user of the document to understand the strength of the literature used to grade each recommendation. Each guideline recommendation is presented as a clinically applicable statement of care and should help the reader make the best patient-care decision. The best available literature was obtained and carefully reviewed. Chapter author(s) completed a thorough literature review using MEDLINE®, the Cochrane Central Registry of Controlled Trials, the Cochrane Database of Systematic Reviews, and other appropriate reference sources. These results of the literature search and review formed the basis of an evidence-based approach to the clinical guidelines. Chapter editors work with authors to ensure compliance with the author’s directives regarding content and format. Then the initial draft is reviewed internally to ensure consistency with the other A.S.P.E.N. Guidelines and Standards and reviewed externally (either by experts in the field within our organization and/or outside of our organization) for appropriateness of content. The final draft is then reviewed and approved by the A.S.P.E.N. Board of Directors.

The system used to categorize the level of evidence for each study or article used in the rationale of the guideline statement and to grade the guideline recommendation is outlined in Table 1.6

Table 1
Grading of Guidelines and Levels of Evidence

The grade of a guideline is based on the levels of evidence of the studies used to support the guideline. A randomized controlled trial (RCT), especially one that is double-blind in design, is considered to be the strongest level of evidence to support decisions regarding a therapeutic intervention in clinical medicine.7 A systematic review (SR) is a specialized type of literature review that analyzes the results of several RCTs. A high-quality SR usually begins with a clinical question and a protocol that addresses the methodology to answer this question. These methods usually state how the literature is identified and assessed for quality, what data are extracted, how they are analyzed, and whether there were any deviations from the protocol during the course of the study. In most instances, meta-analysis (MA), a mathematical tool to combine data from several sources, is used to analyze the data. However, not all SRs use MA.

A level of I, the highest level, will be given to large RCTs where results are clear and the risk of alpha and beta error is low (well-powered). A level of II will be given to RCTs that include a relatively low number of patients or are at moderate to high risk for alpha and beta error (underpowered). A level of III is given to cohort studies with contemporaneous controls or validation studies, while cohort studies with historic controls will receive a level of IV. Case series, uncontrolled studies, and articles based on expert opinion alone will receive a level of V.

Practice Guidelines and Rationales

Table 2 provides the entire set of guideline recommendations for nutrition support in children infected with HIV.

  • 1. Nutrition assessment of children who are HIV+ should be performed at baseline and serially. (Grade: D)

Table 2
Nutrition Support Guideline Recommendations in Children with Human Immunodeficiency Virus (HIV) Infection

Rationale: Growth failure is common in children who are HIV+ and is associated with greater mortality risk. While birth weights and gestational ages are not different among children who are HIV+ and uninfected (HIV−), by age 3 months8,9 and up to 5 years,10 children who are HIV+ have lower weight and height. In fact, wasting syndrome is among the Centers for Disease Control and Prevention (CDC) criteria used to categorize children in clinical category C (severely symptomatic)11 (Table 3). Clinical and laboratory factors associated with this malnutrition include history of pneumonia, maternal illicit drug use during pregnancy, lower infant CD4 count, and increased HIV-1 RNA viral load.10 Decreased nutrient intake, increased energy requirement, malabsorption, and psychosocial issues may all contribute to undernutrition in the pediatric HIV population. Growth failure is a prognostic indicator of mortality in pediatric HIV infection.1214

Table 3
Human Immunodeficiency Virus (HIV) Clinical Categories

See Tables 3 and and44.

  • 2. Anthropometry and body composition studies should be performed. (Grade: E)

Table 4
Nutrition Assessment in Children With HIV Infection

Rationale: Children with HIV infection can have a significant loss of lean body mass, even in the absence of weight loss.18 Weight in children who are HIV+ can be misleading, since fluid shifts caused by vomiting, diarrhea, and altered fluid status can transiently alter the measured weight. Additionally, body mass changes associated with HIV wasting such as preferential loss of fat, loss of lean body mass, and changes in body composition due to HIVLD may not be adequately assessed without body composition evaluation. Anthropometric measures, including mid–arm muscle area, subscapular skinfold, and triceps skinfold, can better reflect fat and lean body mass compared with weight and height measurements alone. Quantification of lean and fat mass is of special importance in these patients due to the increasing incidence of lipodystrophy.

See Table 5.

  • 3. Oral nutritional supplements or enteral tube feedings may improve weight and growth in children who are HIV+ with growth failure. (Grade: C)

Table 5
Anthropometry in Children With Human Immunodeficiency Virus (HIV) Infection

Rationale: When the nutrition assessment indicates that a child fails to meet growth standards, nutritional supplements have restored weight and growth in some children.22 If oral interventions fail, enteral tube feeding improves weight gain in children with growth failure.23,24 In the circumstance of severe malnutrition, nutrition therapy with an elemental diet may be more effective than higher caloric intake of a standard formula for weight gain.25 Accurate energy and protein requirements for children who are HIV+ have not yet been established.

See Table 6.

  • 4. Antiretroviral therapy improves growth in children who are HIV+. (Grade: E)

Table 6
Oral Nutritional Supplements or Enteral Tube Feedings in Children With Human Immunodeficiency Virus (HIV) and Growth Failure

Rationale: Children born to mothers who are HIV+ in both developing and developed countries have lower weight and height z scores from birth to at least 5 years of age.15,21 Growth failure is a prognostic indicator of mortality in pediatric HIV infection.1214 The incidence of wasting has fallen since the implementation of HAART; however, multiple factors continue to contribute to growth failure. Children with a virologic response those who reach HIV viral load <400 or 500 copies/mL) or have significant reduction (>1.5 log) in viral load to therapy tend to have a greater increase in weight and height compared with virologic nonresponders.16,26 HAART therapy has been shown to increase weight- and height-for-age, while body mass index (BMI) remains unchanged.16,26

See Table 7.

  • 5. Children with HIV lipodystrophy should have laboratory evaluation and clinical management of hypertriglyceridemia and hypercholesterolemia. (Grade: D)

Table 7
Growth in Children With Human Immunodeficiency Virus (HIV) and Treated With Antiretroviral Therapy

Rationale: While initiation of HAART includes many benefits, it has transformed HIV into a chronic disease with the increased risk of metabolic complications. HIVLD has 3 main components: abnormal blood lipid profiles (hypertriglyceridemia and hypercholesterolemia), insulin resistance, and body fat redistribution.30 Children and adolescents who are HIV+ may exhibit features of lipohypertrophy, lipoatrophy, or a combination of the 2. Lack of consensus of the definition of HIVLD has made its characterization difficult. Moreover, signs of HIVLD are more difficult to identify in children and adolescents than in adults because of subtle fat redistribution and physical changes during puberty. Estimates of the prevalence of HIVLD in children and adolescents range from 13% to 67%.19,27,3034 The development of symptoms has been linked to protease inhibitor (PI) therapy,3335 duration of HAART therapy,30,33 nucleoside analog–containing regimens, and increasing doses of medications.36 There is increased association of HIVLD with puberty33,37 and female gender.30 Management of lipodystrophy complications in children who are HIV+ has not been well studied.

See Table 8.

  • 6. Supplementation with multivitamins should be provided to pregnant and lactating women who are HIV+. (Grade: B)

Table 8
Lipodystrophy in Children With Human Immunodeficiency Virus (HIV)

Rationale: Supplementation with standard pregnancy multivitamins in pregnant and lactating women in the developing world has been associated with improved fetal and childhood outcomes in 1 large randomized control trial.3942 In this trial, multivitamin supplementation was shown to improve infant outcomes (eg, decrease prematurity, increase birth weight, decrease the incidence of small gestational age infants) and to improve childhood outcomes (higher CD4 counts, decreased diarrhea, and improved development).3942 Another trial investigated the effects of zinc supplementation vs placebo on pregnant women and found no adverse effects on woman or infants compared with pregnant mothers who received placebo.43

Because of its recognized modulation of the immune system, supplemental vitamin A was investigated in pregnant women who are HIV+. While some trials found improved infant outcomes (Table 9), 2 large trials suggested an increased rate of mother-to-child HIV transmission in a subset of the population with high-dose supplemental vitamin A,44,45 while other smaller trials found no effect.46,47 High-dose vitamin A supplementation in HIV+ mothers is not currently recommended, since it does not reduce4749 and may increase mother-to-child HIV transmission.44

Table 9
Multivitamin (MV) Supplementation in Mothers With Human Immunodeficiency Virus (HIV) Infection

See Table 9.

  • 7. Micronutrient supplementation should be considered in children who are HIV+. (Grade: C)

Rationale: The micronutrient status of children who are HIV+ continues to be an area of intense research. Supplementation of multivitamins and micronutrients, at the required dietary allowance dosage, may be indicated in children who are HIV+. In the United States, children who are HIV+ may have reduced dietary intake of vitamin E,51 calcium, and vitamin D.52 Consumption of a multivitamin is associated with better bone mineral density in children who are HIV+.52 Selenium deficiency has been linked with increased mortality risk in children who are HIV+.53 The majority of research to date has been conducted in developing countries where micronutrient deficiencies are common regardless of HIV status, making it difficult to differentiate the etiology of nutrient deficiencies secondary to HIV/AIDS or background rates of micronutrient malnutrition. In 1 study, vitamin A supplementation in children who are HIV+ was shown to decrease diarrhea, upper respiratory tract infections, and mortality.54,55 In another study, zinc supplementation was associated with no change in respiratory tract infection, CD4 counts, or HIV viral load, but it decreased diarrhea illness in children who are HIV+.56

See Table 10.

  • 8. Women who are HIV+ in resource-rich settings are advised to formula feed exclusively, while in resource-poor settings, exclusive breastfeeding is recommended. (Grade: B)

Table 10
Micronutrient Supplementation in Children With Human Immunodeficiency Virus (HIV) Infection

Rationale: HIV transmission through breastfeeding may account for as much as 12%–16% of postnatal transmission.5961 In developed countries, it is recommended that mothers who are HIV+ exclusively formula feed to avoid the risk of HIV transmission.62 In resource-poor settings, the practical aspects of implementation of formula feeding may be difficult due to unsafe water, lack of availability of milk substitutes, varying cultural norms, and risk of maternal stigmatization.62 Maternal characteristics that place infants at increased risk for HIV transmission include higher plasma and milk HIV viral load, mastitis, and decreased maternal CD4 count.62 Furthermore, the protective factors of breastfeeding in these environments may include decreased diarrheal illness and decreased mortality. The World Health Organization recommends that when replacement feeding is feasible, acceptable, affordable, sustainable, and safe, then avoidance of breastfeeding by women who are HIV+ is recommended.63 Otherwise, in the developing world, the morbidity and mortality of infants born to mothers who are HIV+, whether exclusively fed breast milk or formula, may be equivocal.64,65,66 Should breastfeeding be selected, exclusive breastfeeding is advised, as it is associated with decreased vertical transmission and infant mortality compared with mixed feeding regimens.60,67 Furthermore, a 6-month period of exclusive breastfeeding may be recommended, as the risk of transmission significantly increases with time.67 Peripartum maternal and infant antiretroviral prophylaxis during breastfeeding may also decrease the risk of HIV transmission to the infant postnatally.

See Table 11.

Table 11
Breastfeeding (BF) in Children With Human Immunodeficiency Virus (HIV) Infection


We acknowledge the contributions of Tim Sentongo, MD, and Charlene Compher, PhD, RD, FADA, LDN, CNSC.


A.S.P.E.N. Board of Directors Providing Final Approval

Mark R Corkins, MD; Tom Jaksic, MD, PhD; Elizabeth M Lyman, RN, MSN; Ainsley M Malone, RD, MS; Stephen A McClave, MD; Jay M Mirtallo, RPh, BSNSP; Lawrence A Robinson, PharmD; Kelly A Tappenden, RD, PhD; Charles Van Way III, MD; Vincent W Vanek, MD; and John R Wesley, MD.


1. A.S.P.E.N. Board of Directors. Guidelines for use of total parenteral nutrition in the hospitalized adult patient. JPEN J Parenter Enteral Nutr. 1986;10(5):441–445. [PubMed]
2. A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1 suppl):1SA–138SA. [PubMed]
3. A.S.P.E.N. Board of Directors. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN J Parenter Enteral Nutr. 1993;17(suppl 4):1SA–52SA. [PubMed]
4. Committee to Advise Public Health Service on Clinical Practice Guidelines (Institute of Medicine) Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990. p. 58.
5. Seres D, Compher C, Seidner D, Byham-Gray L, Gervasio J, McClave S. 2005 American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards and Guidelines survey. Nutr Clin Pract. 2006;21(5):529–532. [PubMed]
6. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32(3):858–873. [PubMed]
7. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ Guides to the Medical Literature, XXV: evidence-based medicine: principles for applying the Users’ Guides to patient care. Evidence-Based Medicine Working Group. JAMA. 2000;284(10):1290–1296. [PubMed]
8. Bailey RC, Kamenga MC, Nsuami MJ, Nieburg P, St Louis ME. Growth of children according to maternal and child HIV, immunological and disease characteristics: a prospective cohort study in Kinshasa, Democratic Republic of Congo. Int J Epidemiol. 1999;28(3):532–540. [PubMed]
9. McKinney RE, Jr, Robertson JW. Effect of human immunodeficiency virus infection on the growth of young children. Duke Pediatric AIDS Clinical Trials Unit. J Pediatr. 1993;123(4):579–582. [PubMed]
10. Miller TL, Easley KA, Zhang W, et al. Maternal and infant factors associated with failure to thrive in children with vertically transmitted human immunodeficiency virus-1 infection: the prospective, P2C2 human immunodeficiency virus multicenter study. Pediatrics. 2001;108(6):1287–1296. [PMC free article] [PubMed]
11. CDC. MMWR, editor. 1994 Revised classification system for human immunodeficiency infection in children less than 13 years of age. Centers for Disease Control Surveillance Summary. 1994;Vol. 43:1–9.
12. Berhane R, Bagenda D, Marum L, et al. Growth failure as a prognostic indicator of mortality in pediatric HIV infection. Pediatrics. 1997;100(1):E7. [PubMed]
13. Lepage P, Msellati P, Hitimana DG, et al. Growth of human immunodeficiency type 1-infected and uninfected children: a prospective cohort study in Kigali, Rwanda, 1988 to 1993. Pediatr Infect Dis J. 1996;15(6):479–485. [PubMed]
14. Villamor E, Misegades L, Fataki MR, Mbise RL, Fawzi WW. Child mortality in relation to HIV infection, nutritional status, and socioeconomic background. Int J Epidemiol. 2005;34(1):61–68. [PubMed]
15. Newell ML, Borja MC, Peckham C. Height, weight, and growth in children born to mothers with HIV-1 infection in Europe. Pediatrics. 2003;111(1):e52–e60. [PubMed]
16. Verweel G, van Rossum AM, Hartwig NG, Wolfs TF, Scherpbier HJ, de Groot R. Treatment with highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children is associated with a sustained effect on growth. Pediatrics. 2002;109(2):E25. [PubMed]
17. Miller TL, Mawn BE, Orav EJ, et al. The effect of protease inhibitor therapy on growth and body composition in human immunodeficiency virus type 1-infected children. Pediatrics. 2001;107(5):E77. [PubMed]
18. Miller TL, Evans SJ, Orav EJ, Morris V, McIntosh K, Winter HS. Growth and body composition in children infected with the human immunodeficiency virus-1. Am J Clin Nutr. 1993;57(4):588–592. [PubMed]
19. Taylor P, Worrell C, Steinberg SM, et al. Natural history of lipid abnormalities and fat redistribution among human immunodeficiency virus-infected children receiving long-term, protease inhibitor-containing, highly active antiretroviral therapy regimens. Pediatrics. 2004;114(2):e235–e242. [PubMed]
20. Jaquet D, Levine M, Ortega-Rodriguez E, et al. Clinical and metabolic presentation of the lipodystrophic syndrome in HIV-infected children. AIDS. 2000;14(14):2123–2128. [PubMed]
21. Arpadi SM, Horlick MN, Wang J, Cuff P, Bamji M, Kotler DP. Body composition in prepubertal children with human immunodeficiency virus type 1 infection. Arch Pediatr Adolesc Med. 1998;152(7):688–693. [PubMed]
22. Rollins NC, van den Broeck J, Kindra G, Pent M, Kasambira T, Bennish ML. The effect of nutritional support on weight gain of HIV-infected children with prolonged diarrhoea. Acta Paediatr. 2007;96(1):62–68. [PubMed]
23. Miller TL, Awnetwant EL, Evans S, Morris VM, Vazquez IM, McIntosh K. Gastrostomy tube supplementation for HIV infected children. Pediatrics. 1995;96(4 Pt 1):696–702. [PubMed]
24. Henderson RA, Saavedra JM, Perman JA, Hutton N, Livingston RA, Yolken RH. Effect of enteral tube feeding on growth of children with symptomatic human immunodeficiency virus infection. J Pediatr Gastroenterol Nutr. 1994;18(4):429–434. [PubMed]
25. Amadi B, Mwiya M, Chomba E, et al. Improved nutritional recovery on an elemental diet in Zambian children with persistent diarrhoea and malnutrition. J Trop Pediatr. 2005;51(1):5–10. [PubMed]
26. Guillen S, Ramos JT, Resino R, Bellon JM, Munoz MA. Impact on weight and height with the use of HAART in HIV+ children. Pediatr Infect Dis J. 2007;26(4):334–338. [PubMed]
27. Scherpbier HJ, Bekker V, van Leth F, Jurriaans S, Lange JM, Kuijpers TW. Long-term experience with combination antiretroviral therapy that contains nelfinavir for up to 7 years in a pediatric cohort. Pediatrics. 2006;117(3):e528–e536. [PubMed]
28. Nachman SA, Lindsey JC, Moye J, et al. Growth of human immunodeficiency virus-infected children receiving highly active antiretroviral therapy. Pediatr Infect Dis J. 2005;24(4):352–357. [PubMed]
29. Arpadi SM. Growth failure in children with HIV infection. J Acquir Immune Defic Syndr. 2000;25(suppl 1):S37–S42. [PubMed]
30. Ene L, Goetghebuer T, Hainaut M, Peltier A, Toppet V, Levy J. Prevalence of lipodystrophy in HIV+ children: a cross-sectional study. Eur J Pediatr. 2007;166(1):13–21. [PubMed]
31. Sanchez Torres AM, Munoz Muniz R, Madero R, Borque C, Garcia-Miguel MJ, De Jose Gomez MI. Prevalence of fat redistribution and metabolic disorders in human immunodeficiency virus-infected children. Eur J Pediatr. 2005;164(5):271–276. [PubMed]
32. Carter RJ, Wiener J, Abrams EJ, et al. Dyslipidemia among perinatally HIV+ children enrolled in the PACTS-HOPE cohort, 1999–2004: a longitudinal analysis. J Acquir Immune Defic Syndr. 2006;41(4):453–460. [PubMed]
33. Beregszaszi M, Dollfus C, Levine M, et al. Longitudinal evaluation and risk factors of lipodystrophy and associated metabolic changes in HIV+ children. J Acquir Immune Defic Syndr. 2005;40(2):161–168. [PubMed]
34. Farley J, Gona P, Crain M, et al. Prevalence of elevated cholesterol and associated risk factors among perinatally HIV+ children (4–19 years old) in Pediatric AIDS Clinical Trials Group 219C. J Acquir Immune Defic Syndr. 2005;38(4):480–487. [PubMed]
35. Arpadi SM, Cuff PA, Kotler DP, et al. Growth velocity, fat-free mass and energy intake are inversely related to viral load in HIV+ children. J Nutr. 2000;130(10):2498–2502. [PubMed]
36. Amaya RA, Kozinetz CA, McMeans A, Schwarzwald H, Kline MW. Lipodystrophy syndrome in human immunodeficiency virus-infected children. Pediatr Infect Dis J. 2002;21(5):405–410. [PubMed]
37. Hartman K, Verweel G, de Groot R, Hartwig NG. Detection of lipoatrophy in human immunodeficiency virus-1-infected children treated with highly active antiretroviral therapy. Pediatr Infect Dis J. 2006;25(5):427–431. [PubMed]
38. Antiretroviral therapy, fat redistribution and hyperlipidaemia in HIV+ children in Europe. Aids. 2004;18(10):1443–1451. [PubMed]
39. Fawzi WW, Hunter DJ. Vitamins in HIV disease progression and vertical transmission. Epidemiology. 1998;9(4):457–466. [PubMed]
40. Fawzi WW, Msamanga GI, Spiegelman D, et al. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania. Lancet. 1998;351(9114):1477–1482. [PubMed]
41. McGrath N, Bellinger D, Robins J, Msamanga GI, Tronick E, Fawzi WW. Effect of maternal multivitamin supplementation on the mental and psychomotor development of children who are born to HIV-1-infected mothers in Tanzania. Pediatrics. 2006;117(2):e216–e225. [PubMed]
42. Villamor E, Saathoff E, Bosch RJ, et al. Vitamin supplementation of HIV+ women improves postnatal child growth. Am J Clin Nutr. 2005;81(4):880–888. [PubMed]
43. Fawzi WW, Villamor E, Msamanga GI, et al. Trial of zinc supplements in relation to pregnancy outcomes, hematologic indicators, and T cell counts among HIV-1-infected women in Tanzania. Am J Clin Nutr. 2005;81(1):161–167. [PubMed]
44. Humphrey JH, Iliff PJ, Marinda ET, et al. Effects of a single large dose of vitamin A, given during the postpartum period to HIV-positive women and their infants, on child HIV infection, HIV-free survival, and mortality. J Infect Dis. 2006;193(6):860–871. [PubMed]
45. Humphrey JH, Hargrove JW, Malaba LC, et al. HIV incidence among post-partum women in Zimbabwe: risk factors and the effect of vitamin A supplementation. AIDS. 2006;20(10):1437–1446. [PubMed]
46. Kumwenda N, Miotti PG, Taha TE, et al. Antenatal vitamin A supplementation increases birth weight and decreases anemia among infants born to human immunodeficiency virus-infected women in Malawi. Clin Infect Dis. 2002;35(5):618–624. [PubMed]
47. Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Randomized trial testing the effect of vitamin A supplementation on pregnancy outcomes and early mother-to-child HIV-1 transmission in Durban, South Africa. South African Vitamin A Study Group. AIDS. 1999;13(12):1517–1524. [PubMed]
48. Fawzi WW, Msamanga GI, Hunter D, et al. Randomized trial of vitamin supplements in relation to transmission of HIV-1 through breastfeeding and early child mortality. AIDS. 2002;16(14):1935–1944. [PubMed]
49. Wiysonge CS, Shey MS, Sterne JA, Brocklehurst P. Vitamin A supplementation for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev. 2005;(4) CD003648. [PubMed]
50. Fawzi WW, Msamanga GI, Wei R, et al. Effect of providing vitamin supplements to human immunodeficiency virus-infected, lactating mothers on the child’s morbidity and CD4+ cell counts. Clin Infect Dis. 2003;36(8):1053–1062. [PubMed]
51. Kruzich LA, Marquis GS, Carriquiry AL, Wilson CM, Stephensen CB. US youths in the early stages of HIV disease have low intakes of some micronutrients important for optimal immune function. J Am Diet Assoc. 2004;104(7):1095–1101. [PubMed]
52. Jacobson DL, Spiegelman D, Duggan C, et al. Predictors of bone mineral density in human immunodeficiency virus-1 infected children. J Pediatr Gastroenterol Nutr. 2005;41(3):339–346. [PubMed]
53. Campa A, Shor-Posner G, Indacochea F, et al. Mortality risk in selenium-deficient HIV-positive children. J Acquir Immune Defic Syndr Hum Retrovirol. 1999;20(5):508–513. [PubMed]
54. Fawzi WW, Mbise RL, Hertzmark E, et al. A randomized trial of vitamin A supplements in relation to mortality among human immunodeficiency virus-infected and uninfected children in Tanzania. Pediatr Infect Dis J. 1999;18(2):127–133. [PubMed]
55. Coutsoudis A, Bobat RA, Coovadia HM, Kuhn L, Tsai WY, Stein ZA. The effects of vitamin A supplementation on the morbidity of children born to HIV+ women. Am J Public Health. 1995;85(8 pt 1):1076–1081. [PubMed]
56. Bobat R, Coovadia H, Stephen C, et al. Safety and efficacy of zinc supplementation for children with HIV-1 infection in South Africa: a randomised double-blind placebo-controlled trial. Lancet. 2005;366(9500):1862–1867. [PubMed]
57. Tremeschin MH, Cervi MC, Camelo Júnior JS, et al. Niacin nutritional status in HIV type 1-positive children: preliminary data. J Pediatr Gastroenterol Nutr. 2007;44(5):629–633. [PubMed]
58. Semba RD, Ndugwa C, Perry RT, et al. Effect of periodic vitamin A supplementation on mortality and morbidity of human immunodeficiency virus-infected children in Uganda: a controlled clinical trial. Nutrition. 2005;21(1):25–31. [PubMed]
59. Nduati R, John G, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA. 2000;283(9):1167–1174. [PubMed]
60. Iliff PJ, Piwoz EG, Tavengwa NV, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS. 2005;19(7):699–708. [PubMed]
61. Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet. 1992;340(8819):585–588. [PubMed]
62. Kourtis AP, Jamieson DJ, de Vincenzi I, et al. Prevention of human immunodeficiency virus-1 transmission to the infant through breastfeeding: new developments. Am J Obstet Gynecol. 2007;197(3 suppl):S113–S122. [PubMed]
63. WHO UUU. Report of a technical consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV infections in pregnant women, mother and their infants. Paper presented at: HIV and infant feeding: new evidence and programmatic experience; October 2006; Geneva, Switzerland.
64. Bulteel N, Henderson P. Evidence behind the WHO guidelines: hospital care for children: what are the risks of formula feeding in children of HIV+ mothers? J Trop Pediatr. 2007;53(6):370–373. [PubMed]
65. Bulteel N, Henderson P. Evidence behind the WHO guidelines: hospital care for children: what are the risks of HIV transmission through breastfeeding? J Trop Pediatr. 2007;53(5):298–302. [PubMed]
66. Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV+ mothers in Africa: a pooled analysis. Lancet. 2004;364(9441):1236–1243. [PubMed]
67. Coovadia HM, Rollins NC, Bland RM, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007;369(9567):1107–1116. [PubMed]
68. Becquet R, Ekouevi DK, Menan H, et al. Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d’Ivoire. Prev Med. 2008;47(1):27–33. [PubMed]
69. Rollins NC, Becquet R, Bland RM, Coutsoudis A, Coovadia HM, Newell ML. Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes. AIDS. 2008;22(17):2349–2357. [PMC free article] [PubMed]
70. Kuhn L, Aldrovandi GM, Sinkala M, et al. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med. 2008;359(2):130–141. [PMC free article] [PubMed]
71. Palombi L, Marazzi MC, Voetberg A, Magid NA. Treatment acceleration program and the experience of the DREAM program in prevention of mother-to-child transmission of HIV. AIDS. 2007;21(suppl 4):S65–S71. [PubMed]
72. Taha TE, Hoover DR, Kumwenda NI, et al. Late postnatal transmission of HIV-1 and associated factors. J Infect Dis. 2007;196(1):10–14. [PubMed]
73. Thior I, Lockman S, Smeaton LM, et al. Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study. JAMA. 2006;296(7):794–805. [PubMed]
74. Coutsoudis A, Pillay K, Spooner E, Coovadia HM, Pembrey L, Newell ML. Morbidity in children born to women infected with human immunodeficiency virus in South Africa: does mode of feeding matter? Acta Paediatr. 2003;92(8):890–895. [PubMed]