The increased risk of malnutrition in younger children may be due

The increased risk of malnutrition in younger children may be due to a combination of factors like weaning from the breast, inadequate supplementary feeding, lose of passive immunity received from mother, and so forth, all leading to recurrent infections and a poorly nourished child. After the age of 10 years we see another rise in the rate of severe malnutrition and this could be explained by the fact that by this age many children start showing evidence of disease progression. In our study we observed that children above 10 years of age had lower mean CD4% and CD4 cell counts, indicating more advanced disease. The CD4 counts were lower in children with stunting and undernutrition compared to the age group as a whole��CD4% which are more stable than absolute counts also showed a decline.

The proportion of children with ��normal�� nutrition decreased with advancing age. Wasting was relatively less prevalent in our cohort suggesting that malnutrition was of chronic onset and not an acute entity, unlike a report from Malawi where the commonest physical sign was wasting in more than 70% of the infected children [16]. While immune status and malnutrition showed a fair correlation, the presence of moderate stunting or undernutrition could not be used to predict disease severity very accurately. Among children with moderate to severe stunting, though the majority had low CD4%, almost one fourth of children in this group had CD4 >15%. Similarly, while underweight (WAZ < ?2) children commonly had CD4 <15%, a quarter of these children also had a CD4% >15%.

The sensitivity and specificity of predicting CD4% using either HAZ or WAZ was not very satisfactory. The area under the ROC curve for both WAZ and HAZ was in the range of 0.6�C0.7, indicating poor diagnostic accuracy. Because malnutrition is common at all stages of HIV disease, stunting or undernutrition cannot be used as a surrogate marker for predicting disease stage or severity. Our study also highlights the fact that even at relatively early stages of the disease with higher CD4 counts, malnutrition is a substantial problem with over a third of children moderately or severely malnourished. By the time they reach a stage of advanced immunodeficiency, approximately three-quarters are stunted and underweight. Hence, there is a need for nutritional intervention at an early stage of the disease, as stunting may not be completely reversible if it is long standing.

The strengths of our study are that this was a group of well-characterized HIV-infected Anacetrapib children representing all age groups. Both anthropometric and CD4 measurements were performed using standardized methods. There are a few limitations to our study. Since this study was cross-sectional in design, it was difficult to examine any temporal relationships between malnutrition and disease outcomes.

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