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Guideline Summary
Guideline Title
A.S.P.E.N. clinical guidelines: nutrition support of children with human immunodeficiency virus infection.
Bibliographic Source(s)
Sabery N, Duggan C, American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support of children with human immunodeficiency virus infection. JPEN J Parenter Enteral Nutr. 2009 Nov-Dec;33(6):588-606. [74 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Human immunodeficiency virus (HIV) infection

Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Critical Care
Family Practice
Infectious Diseases
Internal Medicine
Nursing
Nutrition
Pediatrics
Pharmacology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide guidelines for maintaining the nutrition status of the human immunodeficiency virus (HIV) infected child which is crucial for optimal health outcomes
  • To provide educational tools to influence institutional practices and resource allocation
Target Population
  • Children and adolescents with human immunodeficiency virus (HIV) infection
  • HIV-positive mothers
Interventions and Practices Considered

Assessment/Diagnosis

  1. Nutrition assessment
  2. Anthropometry, body composition studies
  3. Evaluation for hypertriglyceridemia, hypercholesterolemia

Management/Treatment

  1. Nutritional supplementation
    • Oral supplements
    • Enteral tube feedings
  2. Antiretroviral therapy
  3. Management of hypertriglyceridemia, hypercholesterolemia
  4. Micronutrient supplementation
  5. Multivitamin supplementation for human immunodeficiency virus (HIV) positive pregnant and lactating women
  6. Exclusive breastfeeding or formula feeding (as indicated)
Major Outcomes Considered
  • Growth failure
  • Malnutrition
  • Mortality
  • Life span
  • Human immunodeficiency virus associated lipodystrophy (HIVLD)

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

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.

Published literature through 2008 was searched and reviewed.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

I Large randomized trials with clear-cut results; low risk of false-positive (alpha) and/or false-negative (beta) error
II Small, randomized trials with uncertain results; moderate to high risk of false-positive (alpha) and/or false-negative (beta) error
III Nonrandomized cohort with contemporaneous controls
IV Nonrandomized cohort with historical controls
V Case series, uncontrolled studies, and expert opinion
Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

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 of the original guideline document (see the "Rating Scheme for the Strength of Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

These Clinical Guidelines were developed under the guidance of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors.

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."

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 definitive statement of care and should help the reader make the best patient care decision.

The results of the literature search and review formed the basis of an evidence-based approach to the Clinical Guidelines. Chapter editors worked with the authors to ensure compliance with the authors' directives regarding content and format.

Rating Scheme for the Strength of the Recommendations

Grading of Guidelines

A Supported by at least two level I investigations
B Supported by one level I investigation
C Supported by at least one level II investigation
D Supported by at least one level III investigation
E Supported by level IV or V evidence
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The initial draft is reviewed internally to ensure consistency with the other American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Guidelines and Standards and reviewed externally (either by experts in the field within the organization and/or outside of the organization) for appropriateness of content. The final draft is then reviewed and approved by the A.S.P.E.N. Board of Directors.

Recommendations

Major Recommendations

Grades of recommendation (A-E) and levels of evidence (I-V) are defined at the end of the "Major Recommendations" field.

  1. Nutrition assessment of children who are human immunodeficiency virus (HIV) + should be performed at baseline and then serially. (D)
  2. Anthropometry and body composition studies should be performed. (E)
  3. Oral nutritional supplements or enteral tube feedings may improve weight and growth in children who are HIV+ with growth failure. (C)
  4. Antiretroviral therapy improves growth in children who are HIV+. (E)
  5. Children with HIV lipodystrophy should have laboratory evaluation and clinical management of hypertriglyceridemia and hypercholesterolemia. (D)
  6. Supplementation with multivitamins should be provided to pregnant and lactating women who are HIV+. (B)
  7. Micronutrient supplementation should be considered in children who are HIV+. (C)
  8. Women who are HIV+ in resource-rich settings are advised to formula feed exclusively, while in resource poor settings, exclusive breastfeeding is recommended. (B)

Definitions:

Levels of Evidence

I Large randomized trials with clear-cut results; low risk of false-positive (alpha) and/or false-negative (beta) error
II Small, randomized trials with uncertain results; moderate to high risk of false-positive (alpha) and/or false-negative (beta) error
III Nonrandomized cohort with contemporaneous controls
IV Nonrandomized cohort with historical controls
V Case series, uncontrolled studies, and expert opinion

Grading of Guidelines

A Supported by at least two level I investigations
B Supported by one level I investigation
C Supported by at least one level II investigation
D Supported by at least one level III investigation
E Supported by level IV or V evidence
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence ranges from prospective randomized trials to expert opinion/consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved nutritional status and health outcomes for the human immunodeficiency virus (HIV)-infected child

Potential Harms
  • While initiation of highly active antiretroviral therapy (HAART) includes many benefits, it has transformed HIV into a chronic disease with the increased risk of metabolic complications.
  • HIV transmission through breastfeeding may account for as much as 12%–16% of postnatal transmission. 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.

Qualifying Statements

Qualifying Statements

The American Society for Parenteral and Enteral Nutrition (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.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Sabery N, Duggan C, American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support of children with human immunodeficiency virus infection. JPEN J Parenter Enteral Nutr. 2009 Nov-Dec;33(6):588-606. [74 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Nov-Dec
Guideline Developer(s)
American Society for Parenteral and Enteral Nutrition - Professional Association
Source(s) of Funding

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

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

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Journal of Parenteral and Enteral Nutrition Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on January 11, 2013. The information was verified by the guideline developer on February 1, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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