Step 7Discuss exercise and avoiding risk factors for malnutrition

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Key message 7

Physical activity and play help children to develop and maintain strong muscles and improve their sense of well-being. Maintaining good nutritional status enables HIV-infected children to fight and avoid infections such as diarrhoea. Preventive measures such as good hygiene, immunisations and regular vitamin A supplements similarly protect the child against infections and undernutrition.

  • Discuss importance of maintaining good nutritional status
  • Discuss Exercise and Play
  • Discuss Avoiding infections including avoiding contact with patients with active TB and use of insecticide-treated bednets (in malaria endemic areas)
  • Discuss Hygiene and food safety
  • Check that Immunizations are up to date
  • Check that child is receiving daily cotrimoxazole, and regular supply of these medicines from the clinic
  • Check that child has received deworming medicine every 6 months. If not, treat
  • Check that child has received vitamin A - every 6 months (IMCI schedule). If not, then give

Exercise and play

Healthy children enjoy playing; through play they learn and develop both intellectual and physical skills. HIV infected children, when their disease advances, often lose their muscle strength and the muscles become smaller. Losing muscle is harmful to the body and is a sign that the disease is progressing. At this stage the child probably needs ART.

Most clinics and hospitals cannot measure whether a child has a lot, or a little muscle in his/her body. Most facilities measure routinely only weight. Feeling the amount of muscle (muscle bulk) in the child's upper arm is helpful but not very accurate. Some hospitals and dieticians can do other measurements that can accurately measure muscle bulk but even at these facilities it is not necessary to measure muscle bulk at every visit.

When HIV-infected children are feeling well or only having occasional periods of illness, regular play and activity can help to build up their muscles. Regular exercise is also helpful in developing and maintaining their appetite. It is important for children to allocate time to build up their weight and especially muscle bulk through regular play and age-appropriate activity. And this is what children love to do – so they will feel better and will enjoy themselves more! It is also a great way for mothers, fathers, and other caregivers to show that they love the child and to enjoy their child.

When admitted to hospital, in addition to the discomfort of the physical illness and hospital procedures e.g. blood sampling, children are often extremely distressed by the separation from parents and caregivers. Play and exercise may be one way to help children deal with this stress and even help ward staff deal with their own emotions brought on by children crying or being distressed.

Avoiding infections

It is better to avoid infections than to need to treat them. There are several simple and practical ways by which parents and caregivers can help their children avoid common infections, and so protect against malnutrition. These suggestions also help the mother or father to take some control and influence their child's health. Many HIV-infected mothers and fathers feel very guilty that they have ‘given’ HIV to their child and do not know how they can help the child remain well and be able to enjoy life. If mothers, fathers or other caregivers have simple guidance and knowledge about how they may improve the health of the child, they may recover their own sense of dignity and self-worth.

Ways to avoid infections


Maintain good nutrition


Hygiene and food safety




Regular (prophylactic) cotrimoxazole


Regular (prophylactic) vitamin A




Avoiding contact with patients with active TB


Avoiding malaria through use of insecticide-treated bednets (in malaria endemic areas)

Hygiene and food safety

All children are more likely to get diarrhoea and become sick if parents and caregivers do not store and prepare food in a safe and hygienic way. Diarrhoeal illnesses increase nutritional losses and requirements and frequently cause weight loss in children. Children with HIV infection are especially vulnerable. This is also true for parents who are HIV-infected. Clean and safe food practices are therefore important for everyone. Unsafe water and food can make a person ill. Therefore, prevention of infection from contaminated food and water is very important. Health care workers should discuss with mothers and caregivers ways in which they can keep food clean and safe in their households.

These include:4

wash hands before preparing, and eating food;

keep utensils and food preparation areas clean;

separate raw and cooked foods;

cook food thoroughly;

keep food at a safe temperature.

Healthcare workers need to use good communication skills i.e. carefully look and listen to what a family is currently doing and find something in their practices to praise. Relevant information on what are safe practices for food preparation and handling can then be given. Healthcare workers can offer suggestions and discuss ways the household can apply safe food practices considering its particular situation. It is essential to check that the mothers or caregivers understand, decide and are able to carry out their decisions; it is not helpful to just tell them what they should do.


Routine childhood immunizations are very effective in preventing some common and serious childhood infections such as pertussis (whooping cough) and measles. HIV-infected children who develop measles have a more serious illness and are more likely to die.

In the event of exposure e.g. to chicken pox or measles, HIV-infected children especially those with severe immunosuppression should receive immunoglobulin.

  • Varicella immunoglobulin (0.15 ml/kg) within 3 days of exposure
  • Measles immunoglobulin (0.5 ml/kg, max 15 ml) within 6 days of exposure

Regular (prophylactic) cotrimoxazole5

All HIV-infected children should receive prophylactic cotrimoxazole following the guidelines provided below to prevent PCP pneumonia.

Cotrimoxazole formulations and dosage for infant and children living with HIV or exposed to HIV.


Cotrimoxazole formulations and dosage for infant and children living with HIV or exposed to HIV.

With current evidence it is not yet clear if cotrimoxazole continues to provide protection after immune restoration is achieved.

How long should cotrimoxazole be given

  • HIV infected children:
    • where ARV treatment is not yet available, indefinitely
    • where ART is available, continue until five years of age
  • HIV exposed children8 – until HIV infection has been definitively ruled out AND the mother is no longer breastfeeding

Defining HIV infection: For children younger than 12-18 months, HIV infection can only be confirmed by virological testing. It is recommended that infants known to be exposed to HIV should have a virological test (HIV nucleic acid test) at 4-6 weeks of age or at the earliest opportunity for infants seen after 4-6 weeks. Additionally, urgent HIV testing is recommended for any infant presenting to health facilities with signs, symptoms or medical conditions that could indicate HIV infection.

Under what circumstances should cotrimoxazole be discontinued

  • Occurrence of severe cutaneous reactions such as Stevens Johnson syndrome, renal and/or hepatic insufficiency or severe haematological toxicity.
  • In an HIV-infected child:

    If the child is on ARV therapy, cotrimoxazole can be stopped ONLY when evidence of sustained immune restoration has occurred and the child is over 5 years of age.

    Sustained immune restoration is achieved when the child is stable on antiretroviral therapy with good adherence, has secure access to antiretroviral therapy and has CD4 and clinical evidence of immune recovery in accordance with the recommendations for adults and adolescents (usually CD4% >15 or CD4 >200 for at least 6 months, demonstrated at two measurements, at least 3 to 6 months apart).

    If ARV therapy is not available, cotrimoxazole should not be discontinued.

  • In an HIV exposed child or infant ONLY once HIV infection has confidently been excluded and at least six weeks have elapsed after complete cessation of breastfeeding.

    HIV exposed child or infant <18 months – negative virological testing if conducted 6 weeks after complete cessation of breastfeeding usually indicates the infant is not infected.

    For a breastfed HIV-exposed child >18 months - negative HIV antibody testing 6 weeks after complete cessation of breastfeeding usually denotes the child is not infected.

Regular (prophylactic) vitamin A supplements every 4-6 months (IMCI schedule)

Regular vitamin A helps protect HIV-infected children against episodes of severe diarrhoea. In this way vitamin A protects against malnutrition and improves survival in HIV-infected children. For HIV-infected children 6 months to 5 years old, vitamin A supplementation can be given every 6 months in the following doses:



6-12 months 1-5 years

Do not give if child has received dose within the past month e.g. from hospital

For children >5 years, vitamin A should be provided through regular daily micronutrient supplements.


Worm infestation of the intestines can result in poor appetite, anaemia and poor growth. In areas where worm infestations are common, regular deworming is recommended using Albendazole oral, 400 mg single dose every 6 months after the first year of life.


  1. Referral sites need to reinforce and actively support the simple interventions suggested above. Parents and caregivers look to the doctors and nurses at hospitals etc. for approval and confidence on the advice given at clinics.
  2. Referral sites need to take responsibility for checking that prophylactic cotrimoxazole, vitamin A and Albendazole are being dispensed and received by the child. Failures within the health system or movement of children between households and change of caregiver may result in children not receiving these interventions that are known to be beneficial. Referral sites might consider designing their patient review charts to ensure regular documentation of these interventions.
  3. Referral sites and hospital wards/dietician offices may set up demonstration kitchens to practically show mothers and caregivers how best to hygienically prepare and store food.
  4. Referral sites may also be able to go beyond the simple lists above and develop exercise and occupational care programme for children and parents.
  5. When admitted to hospital, in addition to the discomfort of the physical illness and hospital procedures e.g. blood sampling, children are often extremely distressed by the separation from parents and caregivers. Physical activity e.g. play and exercise may be one way to help children deal with this stress and even help ward staff deal with their own emotions brought on by children crying or being distressed.



There is more information on food hygiene included in the appendix.


Guidelines on cotrimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: Recommendations for a public health approach. World Health Organization, Geneva 2006. http://www​​/pub/guidelines/ctxguidelines.pdf


Defined as a child born to mother living with HIV or a child breastfeeding from a mother living with HIV.