Primary Health Care in Paediatric Hiv: Kenya National "Comprehensive Paediatric HIV Care Course". Nascop/Uon/Mu/Knh/Ggch

MODULE 10:
PRIMARY HEALTH CARE IN

PAEDIATRIC HIV
Kenya National “Comprehensive

Paediatric HIV Care Course”.
NASCOP/UoN/MU/KNH/GGCH
Module 10: PHC in Paediatric HIV, 1
October 2007
Goal
This module describes nutritional care,
immunization and growth monitoring of
HIV infected and affected children within
the context of existing primary health care
programs – according to Kenya Ministry of
Health guidelines eg IMCI.
2 Module 10: PHC in Paediatric HIV,

Objectives
At the end of this module the health care worker will be
able to
 Describe the different feeding options for an infant
born to an HIV infected mother.

 Provide nutritional advice to care-givers of HIV
infected children and manage nutritional problems of

HIV infected children
 Provide immunization for HIV infected children
 Discuss growth monitoring in HIV infected children

UNIT:
Nutrition and Paediatric HIV


October 2007
Primary Care of HIV Infected
 10 pillars of Comprehensive care in HIV AIDS
 Confirmation / documentation of Infection
 Staging of Disease
 Treatment of Acute infections and other OIs
 Immunization
 Regular Monitoring of growth and development
 Nutritional care, supplementation and advice
 Prevention of infection including P.C.P./ T.B.
 Counselling for and providing antiretroviral therapy (ART)
 Providing care for mother and family
 Planning for/providing follow up including
community support

Infant feeding in the Context of HIV
 Breastfeeding contributes to mother-to-child
transmission of between 10-20% (if breastfed
for 24 months)
 Increased risk of HIV transmission
postnatally in the following circumstances:
 Maternal disease status
 High maternal viral load
 If mother becomes infected in the postnatal period
 Breast problems e.g. cracked nipples, mastitis
 Sores in the infant’s mouth

Median duration of Breastfeeding
 Sub-Saharan Africa:
21 months
 Near East/North
Africa: 14.8 months
 Asia: 21.3 months
 Latin
America/Caribbean:
13.9 months
Photo: Lora Iannotti

Informed Choice
“HIV and breastfeeding policy supports
breastfeeding for infants of women without
HIV infection or of unknown status and the
right of a woman infected with HIV who is
informed of her sero-status to choose an
infant feeding strategy based on full
information about the risks and benefits of
each alternative.”
UNAIDS/WHO/UNICEF

WHO Infant feeding policy
‘In environments where
replacement feeding is
acceptable, feasible,
affordable,
sustainable and safe,
Diarrhea
Malnutrition avoidance of all
HIV Pneumonia breastfeeding by HIV-
positive women is
recommended from
birth.’

National Infant Feeding Policy
 Feeding Policy for HIV Negative women
(majority) and those unaware of their HIV
status is
 breastfeed exclusively for 6 months
 followed by breastfeeding up to 2 years with
adequate, nutrient rich complementary feeds.
 HIV positive mother should be assisted to
make informed choice on how to safely feed
her infant

Infant feeding options for HIV
positive women
 Replacement feeding
 Exclusive breastfeeding
 Wet nursing
 Heat treated expressed breast milk

I. Replacement Feeding
AFASS: Definitions
Acceptable: the mother perceives no barriers
(cultural, social, fear of stigma or discrimination)
to replacement feeding.
Feasible: the mother or family has adequate time,
knowledge, skills, and other resources to
prepare the replacement food and feed the
infant up to 12 times in 24 hours.
Affordable: the mother and family can pay the
cost of purchasing/producing, preparing & using
replacement without compromising the health
&nutrition of the family
AFASS: Definitions
Sustainable: Availability of a continuous,
uninterrupted supply, of all ingredients
needed for safe replacement feeding, for as
long as the infant needs it, up to the age of
one year or longer.
Safe: replacement feeds can be correctly and
hygienically prepared and stored, then fed in
nutritionally adequate quantities.

Replacement Feeding
Commercial Infant Formula
 Regulated to meet nutritional specifications for first 6
months
 Often fortified with micronutrients including iron
 Usually powder form to be reconstituted with water
 Deficient in breastmilk immune cells/immunoglobulins
 Expensive
 One requires 20kg of formula to feed an infant for 6
months

Replacement Feeding
Commercial Infant Formula
 Often prepared incorrectly and unhygienically
 Bottle frequently used despite advice to use
cups
 Where free or subsidized formula is available
HIV Positive mothers still mix feed babies

Replacement Feeding
Fresh animal milk
 Animal milk is suited for growth of baby animals.
 Modification to suit infants is needed especially
because of high solute load, protein digestibility,

energy content.
 It is difficult to achieve nutritional adequacy with
home modified animal milk even with added

micronutrients when given during entire 6mths.

Replacement Feeding
Fresh Cows’/Goats’/Camels’ Milk
 Has more protein, sodium, phosphorus and other salts
than human milk.
 Has less calories, vitamins and iron than human milk
 Should therefore be modified as follows:
 Age 0-3 months, dilute with water (see below)
 Mix the milk with water and sugar then boil
 Cows’ milk 100ml
 Water 50ml
 Sugar 2 teaspoon (10g)
 Age above 3 months, do not dilute, but add sugar

Replacement Feeding
Fresh Cows’/Goats’/Camels’ Milk
 Supplement micronutrients
 Give a multivitamin supplement
 Give mineral supplement, especially iron

Replacement Feeding
Full Cream milk powder
 Reconstitute according to instructions
on container then add 50% more water

and 2 teaspoons of sugar for every
150ml.( Sugar to taste)

II. Exclusive Breastfeeding
 Exclusive breastfeeding for first months of life
for those who cannot have replacement
feeding.
 Once AFASS REPLACEMENT feeding is

available, breastfeeding can be discontinued.
 These mothers should be supported to

maintain breast health.

EXCLUSIVE BREASTFEEDING
 Avoid mixed feeding (breast feeding+
complementary feeds) as it increases
possibilities of transmitting HIV.
 Techniques e.g. cup and spoon feeding of

expressed breast milk can be used at end of
breastfeeding in preparation for replacement
feeds.

Breastfeeding Technique
 Good positioning
 Correct attachment
 Effective suckling
 Prevention and treatment of cracked
nipples
 Prevention and treatment of mastitis

Transition from exclusive Breastfeeding to
Replacement Feeding
 Duration-2-3 days to 2-3 weeks
 Difficulties in Mother  Difficulties in Baby

 Mastitis  Distress
 Breast Abscess  Restlessness
 Early pregnancy  Loss of Appetite
 Objections from family  Diarrhoea
and Community

III.Wet Nursing
 Acceptable in some cultures.
 Wet nurse should be counselled and tested
to avoid HIV by safe sex.
 Has to be with infant 24 hours a day
 Monitoring HIV status of wet nurse may
be difficult.

IV. Heat Treated
Expressed Breast Milk
 Expressed breastmilk can be pasteurised or
brought to boil and cooled to kill HIV.
 Heat treating reduces level of anti-infective
immune factors.
 Hygienic practices required in handling to
prevent diarrhoea.

Heat Treated Expressed
Breast Milk
 It has been successfully used for sick LBW
infants regardless of HIV status
 Mothers need to be highly motivated
 Sometimes used for transition from exclusive
breastfeeding to replacement feeding.
 No other source of milk; some mothers are
interested and willing to use this method.

Heat Treatment of Expressed
Boiled Milk

Supporting mother to carry out
chosen option - Disclosure
 Disclosure of HIV status to the family:

health worker discusses with mother
importance, steps and ways
Refer to WHO,UNICEF, USAID 2005. HIV and Infant Feeding Counselling Tools, Reference Guide

Supporting mother to carry out
chosen option-Family Option
 Discuss with mother the required and
available family support for the chosen
infant feeding option
 Health worker to discuss with the

family, where possible, the chosen
option

Teaching mother to practice
chosen option
 Start teaching early during pregnancy
 If late in pregnancy start immediately or as

soon as possible after birth
 Have the necessary supplies and equipment

for teaching and demonstration
Refer to WHO,UNICEF, USAID 2005. HIV and Infant Feeding Counselling Tools, Reference Guide

Nutritional issues in the HIV
infected child
 Poor nutrition weakens the immune system
and predisposes to common infections
 HIV infected children are at increased risk of
malnutrition because:
 Low birth weight
 Inappropriate feeding practices
 Household food insecurity
 Orphans

Interaction Between nutrition and HIV
Poor Nutrition
resulting in weight loss,
muscle wasting, weakness,
nutrient deficiencies
Impaired immune system

Increased Nutritional
Poor ability to fight HIV
needs,
Reduced food intake HIV and other infections,
Increased oxidative
and increased loss of stress
nutrients
Increased vulnerability to
infections e.g. Enteric
infections, flu, TB hence
Increased HIV replication,
Hastened disease progression
Increased morbidity
Source: Adapted from RCQHC and Module
FANTA 10:
2003
PHC in Paediatric HIV,
32
Effects of HIV/AIDS on Nutrition
 Reduced birth weight
 Decrease in food intake
 Complicates infant feeding choices
 Impaired nutrient absorption
 Changes in metabolism

Maternal factors associated
with reduced birth weight
 Shorter gestational age among HIV+ women
 High viral load / severe HIV disease
 Intrauterine growth retardation:
 Lower energy intake compared to increased
needs
 Lower vitamin A (multivitamin) status
 Drug or alcohol use during pregnancy

Causes of decreased food consumption
 Mouth and throat sores
 Loss of appetite due to illness, depression,
and changes in mental state
 Side effects of medication
 Abdominal pain, vomiting
 Household food insecurity and poverty

Inadequate intake
 The following can affect oral intake
because of painful lesions of mouth and
oesophagus
 Candidiasis
 herpes simplex stomatitis
 Kaposi’s Sarcoma
 Xerostomia (Dry mouth)
 Excessive mucus production

Poor Nutrient Absorption
 Poor absorption of fats and carbohydrates at
all stages of HIV infection due to
 HIV infection of intestinal cells
 Frequent diarrhea and vomiting
 Opportunistic infections
 Poor absorption of fats causes deficiency of
fat-soluble vitamins such as A and E

Changes in Metabolism
 HIV Infection increases energy requirements by 10%.
 OIs (TB, LIP) increase energy requirements by 25-30%
and to 50% if there is underlying malnutrition.
 There is no data to support increased protein intake.
 Infection increases demand for and utilization of
antioxidant vitamins (E, C, beta-carotene) and minerals
(zinc, selenium, iron)
 Insufficient antioxidants from increased utilization
causes oxidative stress
 Increases HIV replication
 Leads to higher viral loads

Consequences of under nutrition in
HIV infected children
 Severe growth failure among HIV-positive
children is associated with reduced survival.
 Weight loss is associated with HIV infection,
disease progression, and mortality
 Some nutrient deficiencies (vitamins A, B12,
and E, selenium and zinc) are associated with
HIV transmission, disease progression, and
mortality

Strategies to prevent malnutrition and promote
good nutrition
 Provide accurate information and skilled

support to care-givers
 Ensure adequate nutrient in-take
 Provide food fortification and nutrient
supplementation
 Ensure the health and nutritional status of
women and other care-takers
 Prompt treatment for infections (e.g oral
ulcers)

Micronutrients
WHO recommendation:
 Vitamin A
 <6 months 50000 IU
 6-12 months 100000 IU
 12-60 months 200000 IU every 6/12
 Iron: 6mg/kg/day
 Folate <4 months: 2.5 mg/day
>4 months: 5mg /day

Feeding Recommendations for.
Infants and children (IMCI)
 < 6 months if not breastfeeding appropriate

replacement breast milk substitute
 Age 6 to 12 months: adequate servings of thick
enriched uji, mashed foods (e.g. potatoes with
meat, fish, milk/fruit) at least 5 times a day.
 12 months- 2 years : enriched foods as above 5
times per day, family foods, milk 2cups a day.
 2 years and older: enriched family foods
2 snacks between meals

Management of Inadequate
Intake
 Nutrient dense/energy dense foods
 Including nutritional supplements
 Small frequent feeds and snacks
 Consider alternative nutritional support like

parenteral/enteral nutrition.

Fluid and Electrolyte Balance
 Fluid requirements will increase in

presence of diarrhoea, vomiting, night
sweats and prolonged fever.
 These losses should be replaced.

Diet Modification for
persistent diarrhoea
 Investigate cause and treat if infective
 Ensure adequate hydration
 Low lactose diet - replace milk with yoghurt
or lactose free milk.
 Small frequent feeds
 Multivitamin/multi-mineral supplement
 Consume foods at room temperature


Nutritional Management for Common
HIV Related Symptoms
a) Sore mouth/throat

 Soft mouth foods
 Avoidance of spicy/acidic foods
 Cool or room temperature meals
 Nutrient dense, energy dense foods to
maximise intake

Nutritional Management to Common
Nutritional HIV Related Symptoms
b) Nausea
 Small frequent meals
 Avoidance of high-fat greasy foods
 Cool or room temperature foods
 Avoidance of lying down flat after
eating


Nutritional Management for HIV related
symptoms
c) Xerostomia
 Moist foods e.g. gravy
 liquids at meals and extra fluid between
meals
 Good oral hygiene
 Consider prophylactic antifungals

Nutritional Management for common HIV Related
Symptoms
d) Difficulty breathing
 Nutrient dense and energy-dense foods
 Severe resp distress may cause aspiration –
NGT feeds /partial parenteral nutrition
e) Constipation
 Increase fluids
 Dietary fibre

Nutritional Management for Common HIV
Related Symptoms
f) Neurologic Disorders
 CNS manifestations of AIDS like dementia can
reduce intake.
 Reduced sensory perception when chewing
and swallowing can increase risk of

aspiration.
 To help these patients involve other carers
e.g. occupational and physiotherapists.

Paediatric ART and Nutrition
ARV drugs may have side effects and
considerations that impact on nutrition.
 Ritonavir – Taste perversion, G.I intolerance
 Kaletra- Nausea, vomiting, bitter
 Nelfinavir – Diarrhoea, No acidic food
 Abacavir – Nausea, No food restrictions
 Didanosine – Empty stomacha
 Lamivudine – can be taken with food
 Zidovudine – Take with food,nausea,vomiting

Management of Malnourished
HIV Infected Child

Why is nutritional care of severely
malnourished HIV infected children
important?
 Severely malnourished children with HIV/AIDS

are about five times more likely to die than
uninfected children.
 They rarely respond to conventional nutritional
care
 They take much longer to recover

Identifying Children with
Severe Malnutrition
 Look out for visible severe wasting, especially
of the trunk and buttocks
 Look for oedema (swelling) of both feet
 Look for anemia: pallor of the palms and
mucus membranes
 Weigh the child and plot the weight on the
Child Health Card

Classifying Severe Malnutrition
Categorize child with severe malnutrition using table:
Weight for Weight for Oedema

height (%) age (%)
present absent
70 – 79% 60 – 80% Kwashiokor Underweight

< 70% < 60% Marasmus- Marasmus
Kwashiokor
Source: Nutritional Care and Guidelines for PLWHA in Uganda: Guidelines for Service Providers, 2004

Emergency Care
 If the child has a very low body temperature
(below 35 OC) - hypothermia, re-warm the
child and keep the child warm
 Assess for dehydration. If the child is

dehydrated or has diarrhoea, give an oral
rehydration solution to replace lost fluids

Emergency Care
 Prevent hypoglycaemia by initiating early and
frequent (2 hourly) feeds
 If the child has hypoglycaemia (characterized

by drowsiness and stupor),
 Give iv dextrose 10% infusion, 5ml/kg
 give a glucose solution to drink / by NGT
(use intravenous fluids in moderation).

Nutritional Therapy
 Start feeding the child with a therapeutic diet
according to National guidelines, or with foods
that can provide 75 kcal per kg per day at least
within two hours of admission
 Add Vitamin A on days 1, 2 and 14; folic acid 2.5-

5 mg/day and multivitamins.

Emergency Care
 Provide broad-spectrum antibiotics to all

children with severe malnutrition

ART for the child with
severe malnutrition
 Provide antiretroviral medications where
available and affordable
 Children with wasting generally have higher
viral loads and more rapid progression to
death
 ART not only decreases viral load but also had

a positive effect on growth parameters
including weight, weight for height and muscle
mass (Miller et al., 2001)
When to Discharge
 When the weight-for-height reaches 85% of
the mean
 Oedema has cleared
 Has a good appetite
 For older children, able to eat solid food
 Mother/care provider is fully for continued
care at home

At Discharge
 Encourage the mother/caretaker to feed the
child frequently with energy and nutrient-
dense food
 If not already on ARVs prepare the child for

ART or refer to providers of anti-retroviral
therapy services

At Discharge
 Encourage the mother/caretaker to involve
the child in play and stimulation to foster the
child's development.
 Advise the mother/caretaker to take the child

for regular follow-up to ensure the child
completes immunization, receives 6-monthly
vitamin A and undergoes monthly growth
monitoring.

UNIT 2:
Immunization of the HIV
exposed and/or infected child


October 2007
Infected Child
Broad issues in the immunosuppressed child:
 The antigens used in routine child
immunization are safe and confer protection
against the common childhood infections
 Some live vaccines can result in severe
vaccine-associated disease – BCG
 Immune response to vaccines may be
reduced
 Immune response may not be sustained

infected child
 The World Health Organization
Expanded Program on Immunization
(WHO EPI) has provided Guidelines on
how to immunize the HIV infected child
 These have largely been adopted in the
Kenya EPI program

Vaccine Asymptomatic Symptomatic Optimal timing of
HIV HIV immunization
BCG Yes No birth
DPT Yes Yes 6,10,14 wks
OPV* Yes Yes 0, 6,10,14 wks
Measles Yes Yes 6 and 9 months
Hepatitis B Yes Yes As for uninfected

children
Yellow Yes No**
fever
Tetanus Yes Yes 5 doses***
toxoid
* IPV an alternative for children with symptomatic HIV
** Pending further studies
*** 5 doses TT for women of child-bearing age
Immunization of HIV
Infected Infants
 Use National immunization guidelines (KEPI
guidelines)
Of special note
 Measles: give 1st dose at 6 MO; repeat at
9 MO whether symptomatic or not

 BCG and Yellow fever vaccines:
contraindicated in full blown AIDS

Immunization of HIV infected
infants
 Other beneficial vaccines (when available)
 Pneumococcal vaccine (23 valent vaccine from age 2
years, conjugate vaccine age 2, 4 months)
 Varicella-zoster (chicken pox from 15 months)
 Hepatitis A
 Yearly influenza vaccine
 Rotavirus vaccine (2 doses between age 6 weeks and
6 months)
 Avoid missed opportunities for HIV infected
children who are sick

UNIT 3:
Growth and development in
HIV Infected children


October 2007
Growth and Development Monitoring
 Critical child survival strategy in resource poor
settings
 Growth failure is greater in HIV infected
children due to:
 Low birth weight
 HIV infection
 Other underlying disease (e.g TB)
 Inadequate macro and micro- nutrient intake
 Weight, height, development assessment
should be monitored regularly

Why use growth curves?
 Easy and systematic way to follow
changes in growth over time for an
individual child
 Weight, height and head circumference*

should be plotted at regular intervals
 Monthly for HIV infected infants
 Quarterly for older HIV-infected children

How to use and interpret a growth curve
 Measure and weigh the child using the same
method at each visit
 Using age and sex appropriate charts, plot
measurement (weight, height, head
circumference) on the vertical against age on
the horizontal axis
 Compare growth point with previous points
 Assess growth percentile

Failure to Thrive
 Failure to sustain a normal velocity of weight
and/or height growth
 Quantifiable using growth curves
 Often the most sensitive and reliable measure
of disease progression in a child with HIV
infection. May be an indication:
 For ARV treatment in infected infant/child
 Of ARV treatment failure in child on therapy

Development Assessment
 Delayed acquisition of developmental

milestones or loss of previously
acquired skills can be the first sign of
HIV encephalopathy
 Assessment of the child’s development
at regular intervals
 Ask the parents about the child’s
development

Development Assessment
 Simple questions should focus on four critical
developmental domains
 cognitive
 motor
 language
 social
 Assessment is also done through a physical exam
 A developmental checklist may be helpful.
 Assessment of school performance can be done for
older children

Developmental Checklist
1 month Raises head, makes crawling movements, alerts to
sound
2 months Holds head at midline, lifts chest off table, smiles socially
4 months Rolls front to back, laughs
6 months Sits unsupported, babbles
9 months Pulls to stand, says “mama”
12 months Walks alone, uses two words together
18 months Can remove garment of clothing, scribble, use 6 words,

run
24 months Can wash hands, jump up, combine words
36 months Can put on shirt, speech is understandable, can balance

on one foot
48 months Can dress alone, draw a person, use complex speech
(adjectives, prepositions, hop
October 2007
Neuro-Developmental
 Monitor motor milestones
 Gross motor
 Fine motor
 Cognitive development
 Social development
Children with HIV infection may present with

delay or regression of milestones and
successful ART reverses these

Follow-up of HIV Exposed
Children
 At birth – immunization, exposure prophylaxis
 At age 1 to 2 weeks – infant feeding counselling
 At age 6, 10, and 14 weeks - for immunization and
infant feeding counselling
 After 14 weeks, monthly through age 12 months
 After 12 months, every 3 months till 24 months
 After 2 years, a minimum of yearly visits
 At 18 months a confirmatory HIV laboratory test (if
there are no resources for an earlier antigen-based test)

Conclusion
 Primary Health care for HIV infected
and affected infants and children is a
crucial component of comprehensive
care.

Growth Failure Associated with
Increased Risk of Death
4.87
5
Mortality Odds Ratio
4 3.39
3 2.74
0
-1.5 -1 -0.75
Average WAZ in First Year of Life
HIV-infected infants with weight-for-age below –1.5 Z-scores have

five times higher risk of
81 Module
dying before 25 months than10:non-infected
PHC in Paediatric HIV,
children (Berhane et al 1997
Symptom Checklist
Sign or Symptom Yes Sign of Symptom Yes
Cough Pain- muscles
Depression Pain- legs/feet
Diarrhea Pain- other
Difficulty breathing, Poor appetite
shortness of breath
Fatigue Rash
Fever Thrush
Headache Visual problems (new)
Memory problems Weakness
Nausea and/or vomiting Weight loss, failure to
thrive
Night sweats Other 1 (specify):
Numbness or tingling in Other 2 (specify):
legs and/or feet
Pain-abdominal Other 3 (specify):

Primary Health Care in Paediatric Hiv: Kenya National "Comprehensive Paediatric HIV Care Course". Nascop/Uon/Mu/Knh/Ggch

Uploaded by

Copyright:

Available Formats

You might also like

Primary Health Care in Paediatric Hiv: Kenya National "Comprehensive Paediatric HIV Care Course". Nascop/Uon/Mu/Knh/Ggch

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Primary Health Care in Paediatric Hiv: Kenya National "Comprehensive Paediatric HIV Care Course". Nascop/Uon/Mu/Knh/Ggch

Uploaded by

Copyright:

Available Formats

MODULE 10:

PRIMARY HEALTH CARE IN

Kenya National “Comprehensive

2 Module 10: PHC in Paediatric HIV,

born to an HIV infected mother.

infected children and manage nutritional problems of

 Discuss growth monitoring in HIV infected children

3 Module 10: PHC in Paediatric HIV,

Kenya National “Comprehensive

Module 10: PHC in Paediatric HIV, 4

5 Module 10: PHC in Paediatric HIV,

6 Module 10: PHC in Paediatric HIV,

7 Module 10: PHC in Paediatric HIV,

8 Module 10: PHC in Paediatric HIV,

9 Module 10: PHC in Paediatric HIV,

10 Module 10: PHC in Paediatric HIV,

11 Module 10: PHC in Paediatric HIV,

13 Module 10: PHC in Paediatric HIV,

 Usually powder form to be reconstituted with water

 Deficient in breastmilk immune cells/immunoglobulins

 One requires 20kg of formula to feed an infant for 6

14 Module 10: PHC in Paediatric HIV,

 Bottle frequently used despite advice to use

HIV Positive mothers still mix feed babies

15 Module 10: PHC in Paediatric HIV,

 Modification to suit infants is needed especially

because of high solute load, protein digestibility,

home modified animal milk even with added

16 Module 10: PHC in Paediatric HIV,

17 Module 10: PHC in Paediatric HIV,

18 Module 10: PHC in Paediatric HIV,

on container then add 50% more water

19 Module 10: PHC in Paediatric HIV,

 Once AFASS REPLACEMENT feeding is

 These mothers should be supported to

20 Module 10: PHC in Paediatric HIV,

 Techniques e.g. cup and spoon feeding of

21 Module 10: PHC in Paediatric HIV,

22 Module 10: PHC in Paediatric HIV,

 Duration-2-3 days to 2-3 weeks

 Difficulties in Mother  Difficulties in Baby

23 Module 10: PHC in Paediatric HIV,

24 Module 10: PHC in Paediatric HIV,

25 Module 10: PHC in Paediatric HIV,

26 Module 10: PHC in Paediatric HIV,

27 Module 10: PHC in Paediatric HIV,

 Disclosure of HIV status to the family:

28 Module 10: PHC in Paediatric HIV,

 Health worker to discuss with the

29 Module 10: PHC in Paediatric HIV,

 If late in pregnancy start immediately or as

 Have the necessary supplies and equipment

30 Module 10: PHC in Paediatric HIV,

31 Module 10: PHC in Paediatric HIV,

Impaired immune system

33 Module 10: PHC in Paediatric HIV,

34 Module 10: PHC in Paediatric HIV,