Nutritional Assessment of Newborns of HIV Infected Mothers

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Indian Pediatr 2009;46: 339-341

Nutritional Assessment of Newborns of HIV Infected Mothers

J Gangar

From Dr Vaishampayan Memorial Government Medical College, Solapur, Maharashtra, India.Correspondence to: Dr J Gangar, 6, Apurva Apartment, Saat Rasta, Near Chitle Hospital, Solapur 413 001,Maharashtra, India. E-mail: drjinalgangar@...

Manuscript received: October 3, 2007; Initial review completed: January 24, 2008;Revision accepted: June 9, 2008.

Abstract

Nutritional status of 50 newborns born to HIV infected mothers in a tertiary care hospital was compared with that of babies born to HIV seronegative mothers, as assessed by birthweight, mid arm circumference to head circumference ratio (MAC/HC), ponderal index (PI), and clinical assessment of nutritional status (CAN) score. The incidence of malnutrition in babies born to HIV infected mothers was 36%, 82%, 20%, and 44% using birth weight, MAC/HC, PI, and CAN scores, respectively, compared to 10%, 56%, 8%, and 22% incidence in babies born to HIV seronegative mothers, respectively. Rate of fetal malnutrition was significantly more in babies born to HIV infected mothers.

Keywords: Fetal malnutrition, HIV infected mother.

Pediatric AIDS is poised to become a major public health problem in India(1). Nutritional status of the newborn is an important indicator which determines the fetal malnutrition and also neonatal morbidity and mortality in HIV infection(2). Although some data exist about the deleterious effect of HIV infection on the growth of infected children, no data exists about the role of nutritional assessment of newborn of HIV infected mother, subsequent sequelae of the disease or response to treatment in infants or children. This study is directed towards nutritional assessment of newborns of HIV positive mother using anthropometry, Ponderal Index (PI) and Clinical assessment of Nutritional status (CAN) score.

Methods

The study was carried out on 100 neonates delivered at Dr VM Medical College and Government Hospital, Solapur, Maharashtra, India, between January 2006 to December 2006. Fifty liveborn, full term neonates of HIV infected mothers [confirmed using 3 ELISA tests (COMB AIDS Kit)] and 50 liveborn, full term, neonates of HIV seronegative mother were enroled. Only neonates whose hospital stay exceeded 24 hours of age and with a known gestational age (last menstrual period or earliest obstetrical ultrasound) were included. None of the mothers had received antepartum anti retroviral therapy (ART). Mothers with other obstetric and medical diseases affecting fetal outcome were excluded from the study.

All neonates were weighed nude on an electronic weighing scale at birth. Length was measured by infantometer. Head circumference and mid-arm circumference were recorded between 24 hours of birth using a standard non stretchable tape. Ponderal index [PI=Weight in grams×100/length3 (cm)] and MAC/HC ratios(3-5) were calculated from these measurements. A PI of <2.2 and MAC/HC ratio <0.27 were considered as malnutrition. CAN score of <25 was considered malnutrition(6).

Results

In this study 74 neonates born to HIV seropositive mothers were studied. Out of these 24 stillbirths, preterm and babies born to mothers with other obstetric or medical diseases were excluded. The mean birthweight, length, mid-arm circumference and head circumference of the remaining 50 newborns born to HIV seropositive mothers was 2.6±0.4 kg, 46.5±1.7cm, 7.5±1.7 cm, and 32±2.1 cm, respectively, against 2.8±0.4 kg, 48.2±1.3cm, 9.9 ±2.1 cm and 33.7±1.3 cm, respectively in the 50 babies born to HIV seronegative mothers. Thirty-two babies born to HIV seropositive mothers were appropriate for gestational age while 18 were small for gestational age (less than 10th percentile). Table I depicts the relative distribution of nutritional status in neonates in the two groups as assessed by birthweight, MAC/HC ratio, PI and CAN score respectively. The risk of malnutrition (OR) in babies born to HIV seropositive mothers was 5,4,3, and 10 times compared to babies of HIV seronegative mothers using birthweight, MAC/HC ratio, Ponderal index and CAN score as criteria, respectively. The mean weight gain during pregnancy in mothers was 6.5±1.0 kg in HIV seropositive mothers against 7.2±0.8 kg in HIV seronegative mothers. The coefficient of correlation for weight gain of mothers during pregnancy and birthweight of newborn is high (r=0.91) as compared to other anthropometrical measurements (r=0.61).

Table I

Nutritional Status of Newborns as Assessed by Different Methods

Birth weight

MAC/HC ratio

Ponderal index

CAN score

bornto HIV+

bornto HIV–

bornto HIV+

bornto HIV–

bornto HIV+

bornto HIV–

born to HIV+

bornto HIV–

Malnourished

18(36%)

5(10%)

41(82%)

28(56%)

10(20%)

4(8%)

22(44%)

11(22%)

Well nourished

32(64%)

45(90%)

9(18%)

22(44%)

40(80%)

46(92%)

28(56%)

39(78%)

Z value

7.34

6.07

4.98

4.97

P value

0.0002

<0.01

<0.01

<0.05

Discussion

The mean birthweight of neonates of HIV infected mothers is lower than that of standard Indian neonatal value of 2.8kg. Incidence of low birth weight (<2.5kg) in this study is 36% as against standard 30% incidence of LBW in India(7). A Study by and Hassanein(3) proposed that a full term infant is growth retarded if his PI is <2.2. PI relies on the principle that length is spared at the expense of weight during period of acute malnutrition; weight and length velocities may be proportionately impaired so neonates with chronic insult in utero may be misclassified by PI. This attributes the higher values of PI in this study to chronic insult faced by the fetus in utero. Meadow and colleagues(8) concluded in their study that the MAC/HC ratio, independent of birth weight, readily discriminated the late gestation growth retarded baby. Their study showed that this ratio can be used as a reliable test to identify neonates whose growth is retarded, even when their weight does not fall below 10th percentile. The statistically significant low values in this study indicate the late gestational insult that neonates of HIV infected mothers face in utero. The advantage of CAN score is that it is a simple, clinical index for identifying fetal malnutrition and may have the potential to predict neonatal morbidity associated with it without the aid of any sophisticated equipments. The significant increase in PI of neonate of HIV-infected mother, together with decrease in birth weight, MAC/HC ratio and CAN score suggests that HIV infection exposes the infant to chronic insult in utero leading to fetal malnutrition and intrauterine growth retardation.

The main limitation of this study was confounding factors like socioeconomic status, maternal age, parity, nutritional status, micronutrient deficiencies, clinical status, HIV viral load, CD4 count and antiretroviral treatment were not taken into consideration, though all cases were from the same sub-population. Multiple regression analysis study model for each of the potential confounding factors would be essential to attribute the findings of this study to HIV infection. Our results are consistent with several studies in developing countries which have concluded that infants born to HIV infected mothers tend to have lower birth weights than do infants of seronegative women(9-13).

Acknowledgments

The author is grateful to the following staff members of Dr VM Government Medical College, Solapur, Maharashtra, India. Dr PV Kumavat and Dr DV Kurdukar for their guidance and support during the research; Dr Nilesh Shewale for scientific advise, Dr Mulje for assistance in statistical analysis, Dr Suhas Rote and Dr Charusha Salunke for their cooperation in data collection.

Funding: None.

Competing interests: None stated.

What This Study Adds?

• Positive maternal HIV infection status is associated with decreased neonatal birthweight.

References

1. Feasibility study of administering short-term AZT intervention among HIV infected mothers to prevent mother- to- child transmission of HIV in India. Available from: URL: http://www.nacoonline.org/prog_sche_prevent.htm Accessed December 29, 2007.

2. 2006 AIDS epidemic update, Asia. Available from: URL: http://data.unaids.org/pub/EpiReport/2006/05Asia_2006_EpiUpdate_eng.pdf. Accessed December 29, 2007.

3. HC, Hassanein K. Diagnosis of impaired fetal growth in newborn infants.Pediatrics 1971; 48: 511-522.

4. Georgieff MK, Sasanow SR, Chockalingam UM, Pereira GR. A comparison of mid arm/head circumference ratio and Ponderal index for evaluation of mentally retarded infants after abnormal intrauterine growth. Acta Pediatr Scand 1988; 77: 214-219.

5. Kumari S, Jain S, Sethi GR, Yadav M, Saili A, Lai UB. A simple method of screening for intrauterine growth retardation. Indian Pediatr 1988; 55: 283-286.

6. Metcoff J. Clinical assessment of nutritional status at birth: Fetal malnutrition and SGA are not synonymous. Pediat Clin North Am 1994; 41: 875-891.

7. United Nations Childrens Fund (UNICEF). The State of the World's Children 2004. New York: UNICEF; 2004.

8. Meadow NJ, Till J, Leaf A. Screening for intrauterine growth retardation using ratio of midarm circumference to occipitofrontal circumference. Br Med J 1986; 292: 1039-1040.

9. Braddick MR, Kreiss JK, Embree JB, Impact of maternal HIV infection on obstetrical and early neonatal outcome. AIDS 1990; 4:1001-1005.

10. Lepage P, Dabis F, Hitimana DG, Perinatal transmission of HIV-1: lack of impact of maternal HIV infection on characteristics of livebirths and on neonatal mortality in Kigali, Rwanda. AIDS 1991; 5: 295-300.

11. Temmerman M, Chomba EN, Ndinya-Achola J. Maternal human immunodeficiency virus-1 infection and pregnancy outcome. Obstet Gynecol 1994; 83: 495-501.

12. Bulterys M, Chao A, Munyemana S. Maternal human immunodeficiency virus 1 infection and intrauterine growth: a prospective cohort study in Butare, Rwanda. Pediatr Infect Dis J 1994; 13: 94-100.

13. Taha TE, Dallabetta GA, Canner JK. The effect of human immunodeficiency virus infection on birth weight, and infant and child mortality in urban Malawi. Int J Epidemiol 1995; 24: 1022-1029.