Growing Up Info 9

Infos

Pain management and children: How to make it better

On October 12, International Day against Pain, Growing Up Info interviewed Dr. Sophie Laurent, from Douleurs Sans Frontières (Pain without Borders), on managing pain in children and specifically children living with HIV/AIDS.

Growing Up: In what way is managing pain important in caring for children who are HIV positive?

Dr. SL: "Once pain has become chronic, it is no longer a useful diagnostic indicator but a veritable ailment unto itself causing the child to withdraw. Still, we know that in HIV infection, pain is present in 90% of patients at an advanced stage of the illness, under numerous clinical forms: headache, abdominal pain, chest pain; or diffused pain such as arthralgia and neuropathic pain. Assessing chronic pain in younger children is difficult because they don’t describe it spontaneously. While children cry and move around when experiencing acute pain, a child with chronic pain may be “too still”, remain motionless, communicate as little as possible and shelter the painful areas. The healthcare provider should be alerted by his/her apathetic attitude."

Growing Up: What are the most commonly used medicines in Africa to treat pain in children?

Dr. SL: "Paracetamol, but also codeine and morphine, are effective in the treatment of pain in children. Morphine is rarely prescribed in Africa, however, because it is often (wrongly) believed to be addictive when actually, addiction is rare. It is also said to cause respiratory failure, which only happens when the patient has taken an excessive dose. Common physical techniques may also be useful such as counter stimulation (the source of all forms of massage and distraction used by mothers in all societies), hot and cold therapies, massage or drainage, acupuncture, mesotherapie or relaxation techniques. In the case of severe pain, it is important to soothe the pain quickly and to therefore use in conjunction with these physical methods pain relievers including morphine if necessary."

To find out more
Douleurs Sans Frontières website (in French only):
www.douleurs-sans-frontieres.org

The EFIC website:
www.efic.org

Module 8 (« Pain ») of the Paediatric Palliative Care Manual for Home-based Carers (Africaid – AME) – available after registering on the NAM/Aidsmap website: www.aidsmap.com/en/toolkit/download.asp?type=3

Pediadol’s website on pain in children (In French only): www.pediadol.org

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Adherence counseling support: A teaching kit for children and parents

The Belgian non-profit organization "Explain HIV to infected/affected children (EHTIAC)" has designed a teaching kit entitled, "The CD4 counter-attack" to help raise awareness and motivate children living with HIV and their families about taking antiretroviral therapy (ART), parental involvement and gradually explaining to children the reality of the disease. This teaching tool includes 13 medical index cards specifically designed for children 5 years of age and up, a fairy tale appropriate for children as young as 3 year olds, a cartoon about the importance of taking one’s medicines, and a treatment diary that a child can use like an agenda to plan his/her taking medicines and recording any difficulties he/she encounters.

First used in Europe in the context of the PENTA research project, the teaching kit is now being made available to healthcare-providers, parents and children in numerous treatment sites in French and English-speaking Africa. It enables care and support teams to harmonize their disclosure practices, how they support ARV compliance and improve the quality of life of children living with HIV/AIDS. This communication tool reinforces the dialogue on the illness between children and their parents or caregivers. You can also order a training session on how to use this teaching kit from E.H.T.I.A.C.

To find out more
CD4 Counter Attack website
www.aidsandchildren.org

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HIV and malnutrition: a complex relationship

In sub-Saharan Africa, depending on the country, 20 to 70% children with severe malnutrition are infected by HIV. Malnutrition affects almost all HIV + children to varying degrees and at different stages in their lives. Various and complex factors make them vulnerable to malnutrition. HIV itself causes problems: it affects the metabolism of nutrients, increases nutritional needs and can also cause anorexia. Opportunistic infections can aggravate malnutrition: pain and other symptoms may hinder food intake (ie: oral thrush) ; nutritional needs may be increased, for instance when the child has a fever or experiences respiratory distress ; important losses may occur (diarrhea resulting in poor nutrient absorption). Poverty of families living with HIV, will often lead to an insuffiencient food supply. Finally, the weaning period is at higher risk of malnutrition, all the more so since it is recommended that the transition be made as quickly as possible with HIV+ mothers. PMTCT programs should try to focus more attention on dealing with this key period.

In children living with HIV, the most frequent form of malnutrition is marasmus. Monitoring height and weight curves can say more than isolated figures and is essential in following up the child both before and after starting ARV treatment (clinical evaluation of the response to treatment). At all ages for children in whom an HIV diagnosis is confirmed or presumed, antiretroviral therapy should be started in case of severe malnutrition (see WHO recommendations).

If possible, it is advisable to treat the malnutrition before starting ART. Afterwards, the ARV treatment alone is not enough and continuous nutritional support is required. Organizations or international institutions can often help (WFP or CRS for example). We will talk about "How to prevent and treat malnutrition in HIV+ children?" in a forthcoming issue.

To find out more
Report on HIV and nutrition by WHO (May, 2005)
www.who.int/gb/ebwha/pdf_files/EB116/B116_12-en.pdf

WHO recommendations for 2006 on treating children with ARVs. (1.54 Mb)
www.who.int/hiv/pub/guidelines/WHOpaediatric.pdf

Living well with HIV/AIDS:
A manual on nutritional
care and support
for people living
with HIV/AIDS (FAO 2003).
www.fao.org/DOCREP/005/Y4168E/Y4168E00.htm

WFP’s position paper on HIV and malnutrition:
www.wfp.org/English/?ModuleID=137&Key=2213

A Ugandan study on “Severe Malnutrition and HIV” - Bachou H et al - Nutrition Journal 2006, 5:27 (16/10/2006)
www.nutritionj.com/content/5/1/27

Remue-Méninges

An answer to last issue's question

Last month Growing Up Info asked you to counsel a couple of HIV positive parents on why and how to use an impregnated bed net for their newborn. Here is a possible answer:

After having asked the parents where the baby sleeps (with them or by him/herself) I would then introduce the benefits of using an impregnated bednet: "In our country, it is recommended that all newborns be protected by impregnated bednets from mosquitoes that carry malaria. Your child has been exposed to HIV and it renders him/her more vulnerable. That is why these recommendations are even more important in his/her case. Better to prevent than treat and bednets greatly reduce your child’s risk of contracting malaria and needing recourse to expensive medicines. For the last few years, I myself have been using an impregnated bednet and I have felt much better and haven’t had a malaria fever since. Sometimes people complain that it is too hot beneath the netting but I quickly got used to it. Finally, the chemical in which the net has been soaked is not at all toxic and there is nothing to worry about." After these explanations I would demonstrate how to set up the net in the observation room of the health center.

And an exercise on growth curves

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The curves on these growth charts represent the growth (weight and height) of a boy (Paul) and a girl (Yasmine). These children started antiretroviral therapy at a date represented by the arrow. Their growth underwent several fluctuations (letters A & B & C). Please match each letter to an event listed below:

1. An episode of severe pneumonia
2. Problems with adherence
3. Reinforced counselling (home visits, adherence support)

The standard percentile curves on the WHO website:
www.who.int/childgrowth/
standards/chart_catalogue
/en/index.html

Send your answers and explanations to us at: grandir@sidaction.org and win a reference book on HIV/AIDS.

Grandir

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