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Recombinant human growth hormone therapy for cachexia in HIV-infected children
274
NUTRITION
AND
HIV INFECTION-ORAL
PRESENTATIONS
o-27
O-28
M DABBAS-TYAN, M DEBRE, I FUNCK-BRENTANO, C RICOUR, S BLANCHE, 0 GOULET Hopital Necker-Enfants Malades 149, me de Sevres, 75015 Paris, FRANCE ENTERAL NUTRITION IN HUMAN IMMUNODERCIENCY VIRUS INFECTED CHILDREN The decreased growth velocity reflects the protein energy malnutrition of HIVinfected children.The purpose of the current study was to evaluate the effect of enteral feeding (EF) on nutritional status and growth in a cohort of malnourished children with HIV infection. Population: 20 children with symptomatic HIV infection 14 class c3 and 6 class b3, as defined by the Centers for Disease Control classification system, aged 6 to 15 yr (mean 10 yr). Methods: Enteral nutrition was infused via nasogastric tube (II= 17). or gastrostomy (n=3), for a mea” duration of 13 months (range 6-30). All the children received a protein hydrolysate formula via continuous infusion over lo- 12 h. EF was associated with oral feeding in order to provide 2 times the resting energy expenditure calculated “sing Schofield fmmula. All patients were sent home on tube feeding and returned for evaluation at l-3 mo intervals. Anthropometric changes were measured comparing mea” standard deviation (SD) scores before and after enteral nutrition (height, weight, and fat body mass FBM) by “sing four skinfold thickness and Brook equations. Fat free mass (FFM) was measured by “sing bioelectrical impedance analysis (BIA), (5OkH2, Analycor 2 Eugedia) and Houtkooper equations. IGF-1 plasma levels were measured and expressed as % of normal value for age and sex. Results: tube feeding was discontinued due to “on compliance (n=3) intolerance (n=3) within 3 months. 14 children received EF for 6 to 30 mo. No complications due to enteral nutrition were noted. 5 children died after 6.12 mo of EF. IGF-1 plasma levels did not change under enteral feeding.
V VARILLE, A FAYE, M LEVINE, C FAURE, M DUVAL, JP CEZARD, E VILMER, J NAVARRO Hopital Robert Debre, 48 bd Sermier 75019 Paris, FRANCE RESTING ENERGY EXPENDITURE (REE) AND GROWTH VELOCITY (GV) IN HIV-INFECTED CHILDREN Delayed linear GV is a marker of bad prognosis in children infected by HIV. When started early, nutritional support allows catch-up growth in some cases. The aim of the study was 1) to identify the increase in REE early and 2) to compare the REE of HIV children with normal and with impaired GV. Nutritional assessment was carried out twice yearly, at steady state (no fever, no acute infection): caloric intake was noted for 3 days; body composition and GV were measured by anthropometry and REE by indirect calorimetry (Calorimetre Klogor, France). The severity of the disease was estimated “sing the CDC classification for HIV infection. Results: seventeen HIV children (group I), age range 3-15 yr. with delayed GV, were compared with 20 HIV patients (group II), age range 3- 11 yr, growing nmmally, and with 20 healthy children (controlled group), age range 2- 19 yr. All the HIV patients had been contaminated at birth. Average body mass index (BMI as weight/height2) was 25th percentile in group I, 50th percentile in group II and in the controlled group. The average GV was <-2ds in group I and normal in group II and in the controlled group. The fat-free mass was significantly lower in Group I than in the 2 other groups (t-test piO.05) but the fat mass was similar in the 3 groups. The average REE per 24 h was 16% above the Schofield norms 1” group I, 32% above the norms in group II and 4 % above the norm in the control group (p
Before Weight for Age (SD) Height for Age (SD) Weight for Height (SD) Fat Body Mass % Fat Free Mass (BIA) %
-2.25 ~2.54 -1.43 65.65 88.17
2 + t f +
After 0.49 0.87 1.01 27 7.22
~2.07 -2.78 -0.4 16.87 92.52
i t 2 2 i-
P 0.79 0.91 1.2 28.14 8.86
0.05 :;I 0.05 0.05
Conclusion: Enteral nutrition increases weight and FBM. Despite increased FFM. Enteral feeding was unable to correct linear growth deficit.which is probably due to inadequate protein metabolism. O-29
O-30
SC MARRIAGE, M LEVIN Department of Paediatrics, Imperial College School of Medicine at St. Mary’s, London NZ INY UK NATURAL HISTORY OF GROWTH PATTERNS IN CHILDREN WITH ADVANCED HIV INFECTION Background: Although weight loss is a common manifestation of symptomatic HIV infection in adults, in children the clinical picture is made more complex by underlying growth. To improve our understanding of the natural history of growth patterns in paediatric HIV infection, a retrospective analysis of changes in weight, height and body mass index (BMI) of the most severely affected children was undertaken. Method: Children referred to the tertiary Paediatric HIV Unit between January 1990 and December 1996 were eligible for inclusion. Children were categorised by the revised CDC Classification System (MMWR 1994); 40 children presenting with or progressing to clinical category C identified. Growth data (height and weight) were recorded at out-patient visits and ward attendances, and BMI calculated [weight (kg)/height (cm*)]. Data were compared with the 1990 UK reference cwves for growth, and serial standard deviation scores (SDS) calculated using the published LMS method. Significant episodes of weight change (> 0.5 SDS) were related to clinical events and degree of immunosuppression. Results: 5/40 children (13%) died as a consequence of their presenting illness, and no growth data were recorded. Of the remaining 35 children, 21 (60%) have subsequently died, contributing a mea” of 15.6 (range 2.3-35.0) months data. 14 children (40%) are still alive, and have been followed for a median 18.4 (range 11.5-61.2) months. The majority of children presenting with and surviving an AIDS-defining illness achieved “catch-up” growth following treatment and subsequently grew normally. A clear pattern emerged of weight loss during opportunistic infections, but which normalised following recovery. Conclusions: Even in children with advanced HIV infection, weight gain may still occur at a nmmal rate; failure to grow along population centile lines should remain a ca”se for concern and be actively investigated. 1) Cole TJ et al. Cross Sectional Stature and Weight Reference Curves for the UK, 1990. Arch Dis Child, 1995;73:17-24
0 GOULET, G PINTO, R BRAUNER, S BLANCHE, A CLAPIN Hopital Necker Enfants Malades, 149 rue de Sevres, 75748 Paris Cedex 15 FRANCE RECOMBINANT HUMAN GROWTH HORMONE THERAPY FOR CACHEXIA IN HIV-INFECTED CHILDREN Background: Poor statural growth and decreased weight gain are prominent features of pediatric HIV infection. Mammalian cell-derived recombinant-human growth hormone (r-hGH[m]) has been shown to increase lean body mass and body weight and to improve physical performance and quality of life in adults with AIDS wasting. The aim of this preliminary study was to evaluate acceptability, tolerance and efficacy of daily subcutaneous injection of r-hGH[m] in 6 children with HIV-associated failure to thrive. Study design: Main inclusion criteria were HIV positivity, age over 6 and under 15 yrs, height velocity below 2 SD for chronological age, anti-retroviral therapy for more than 1 mo, GH peak s 10 ng/mL Children could receive enteral tube feeding which had to be introduced for at least one month and well tolerated. Children were treated for 28 days with r-hGH[m] 0.2 IUlkgld (0.067 mglkgl d). After the study period, each child was offered on-going therapy with rhGH [m] Outcome parameters included fat-free mass (determined by bioelectrical impedance analysis), weight, CD4 count, HIV RNA, IGF-1 and IGF-BPS. Results: At time of analysis, 5 children (F/M: 3/2; ages: 8, 11,14, 10, 12 yrs) have completed the 28 day study. Three were receiving enteral tube feeding. During the study period, mea” fat-free mass and weight gain were + I. 19 and +0.87 kg, respectively ; r-hGH[m] was well tolerated and no increase in viral load occurred. At the end of the study period, all of the children wanted to continue r-hGH[ m] treatment, giving evidence of good acceptability of the treatment. Data on 6 children, with results from the follow-up period will be presented. Conclusion: These preliminary data of r-hGH[m] treatment for HIV infected children are consistent with those described in adults. All children accepted daily injections of r-hGH [ml. Due to entry criteria, only children with advanced failure to thrive were included in this study. A comparative study is warranted, and should involve children at an earlier stage of disease.
NUTRITION
AND
HIV INFECTION-ORAL
PRESENTATIONS
o-27
O-28
M DABBAS-TYAN, M DEBRE, I FUNCK-BRENTANO, C RICOUR, S BLANCHE, 0 GOULET Hopital Necker-Enfants Malades 149, me de Sevres, 75015 Paris, FRANCE ENTERAL NUTRITION IN HUMAN IMMUNODERCIENCY VIRUS INFECTED CHILDREN The decreased growth velocity reflects the protein energy malnutrition of HIVinfected children.The purpose of the current study was to evaluate the effect of enteral feeding (EF) on nutritional status and growth in a cohort of malnourished children with HIV infection. Population: 20 children with symptomatic HIV infection 14 class c3 and 6 class b3, as defined by the Centers for Disease Control classification system, aged 6 to 15 yr (mean 10 yr). Methods: Enteral nutrition was infused via nasogastric tube (II= 17). or gastrostomy (n=3), for a mea” duration of 13 months (range 6-30). All the children received a protein hydrolysate formula via continuous infusion over lo- 12 h. EF was associated with oral feeding in order to provide 2 times the resting energy expenditure calculated “sing Schofield fmmula. All patients were sent home on tube feeding and returned for evaluation at l-3 mo intervals. Anthropometric changes were measured comparing mea” standard deviation (SD) scores before and after enteral nutrition (height, weight, and fat body mass FBM) by “sing four skinfold thickness and Brook equations. Fat free mass (FFM) was measured by “sing bioelectrical impedance analysis (BIA), (5OkH2, Analycor 2 Eugedia) and Houtkooper equations. IGF-1 plasma levels were measured and expressed as % of normal value for age and sex. Results: tube feeding was discontinued due to “on compliance (n=3) intolerance (n=3) within 3 months. 14 children received EF for 6 to 30 mo. No complications due to enteral nutrition were noted. 5 children died after 6.12 mo of EF. IGF-1 plasma levels did not change under enteral feeding.
V VARILLE, A FAYE, M LEVINE, C FAURE, M DUVAL, JP CEZARD, E VILMER, J NAVARRO Hopital Robert Debre, 48 bd Sermier 75019 Paris, FRANCE RESTING ENERGY EXPENDITURE (REE) AND GROWTH VELOCITY (GV) IN HIV-INFECTED CHILDREN Delayed linear GV is a marker of bad prognosis in children infected by HIV. When started early, nutritional support allows catch-up growth in some cases. The aim of the study was 1) to identify the increase in REE early and 2) to compare the REE of HIV children with normal and with impaired GV. Nutritional assessment was carried out twice yearly, at steady state (no fever, no acute infection): caloric intake was noted for 3 days; body composition and GV were measured by anthropometry and REE by indirect calorimetry (Calorimetre Klogor, France). The severity of the disease was estimated “sing the CDC classification for HIV infection. Results: seventeen HIV children (group I), age range 3-15 yr. with delayed GV, were compared with 20 HIV patients (group II), age range 3- 11 yr, growing nmmally, and with 20 healthy children (controlled group), age range 2- 19 yr. All the HIV patients had been contaminated at birth. Average body mass index (BMI as weight/height2) was 25th percentile in group I, 50th percentile in group II and in the controlled group. The average GV was <-2ds in group I and normal in group II and in the controlled group. The fat-free mass was significantly lower in Group I than in the 2 other groups (t-test piO.05) but the fat mass was similar in the 3 groups. The average REE per 24 h was 16% above the Schofield norms 1” group I, 32% above the norms in group II and 4 % above the norm in the control group (p
Before Weight for Age (SD) Height for Age (SD) Weight for Height (SD) Fat Body Mass % Fat Free Mass (BIA) %
-2.25 ~2.54 -1.43 65.65 88.17
2 + t f +
After 0.49 0.87 1.01 27 7.22
~2.07 -2.78 -0.4 16.87 92.52
i t 2 2 i-
P 0.79 0.91 1.2 28.14 8.86
0.05 :;I 0.05 0.05
Conclusion: Enteral nutrition increases weight and FBM. Despite increased FFM. Enteral feeding was unable to correct linear growth deficit.which is probably due to inadequate protein metabolism. O-29
O-30
SC MARRIAGE, M LEVIN Department of Paediatrics, Imperial College School of Medicine at St. Mary’s, London NZ INY UK NATURAL HISTORY OF GROWTH PATTERNS IN CHILDREN WITH ADVANCED HIV INFECTION Background: Although weight loss is a common manifestation of symptomatic HIV infection in adults, in children the clinical picture is made more complex by underlying growth. To improve our understanding of the natural history of growth patterns in paediatric HIV infection, a retrospective analysis of changes in weight, height and body mass index (BMI) of the most severely affected children was undertaken. Method: Children referred to the tertiary Paediatric HIV Unit between January 1990 and December 1996 were eligible for inclusion. Children were categorised by the revised CDC Classification System (MMWR 1994); 40 children presenting with or progressing to clinical category C identified. Growth data (height and weight) were recorded at out-patient visits and ward attendances, and BMI calculated [weight (kg)/height (cm*)]. Data were compared with the 1990 UK reference cwves for growth, and serial standard deviation scores (SDS) calculated using the published LMS method. Significant episodes of weight change (> 0.5 SDS) were related to clinical events and degree of immunosuppression. Results: 5/40 children (13%) died as a consequence of their presenting illness, and no growth data were recorded. Of the remaining 35 children, 21 (60%) have subsequently died, contributing a mea” of 15.6 (range 2.3-35.0) months data. 14 children (40%) are still alive, and have been followed for a median 18.4 (range 11.5-61.2) months. The majority of children presenting with and surviving an AIDS-defining illness achieved “catch-up” growth following treatment and subsequently grew normally. A clear pattern emerged of weight loss during opportunistic infections, but which normalised following recovery. Conclusions: Even in children with advanced HIV infection, weight gain may still occur at a nmmal rate; failure to grow along population centile lines should remain a ca”se for concern and be actively investigated. 1) Cole TJ et al. Cross Sectional Stature and Weight Reference Curves for the UK, 1990. Arch Dis Child, 1995;73:17-24
0 GOULET, G PINTO, R BRAUNER, S BLANCHE, A CLAPIN Hopital Necker Enfants Malades, 149 rue de Sevres, 75748 Paris Cedex 15 FRANCE RECOMBINANT HUMAN GROWTH HORMONE THERAPY FOR CACHEXIA IN HIV-INFECTED CHILDREN Background: Poor statural growth and decreased weight gain are prominent features of pediatric HIV infection. Mammalian cell-derived recombinant-human growth hormone (r-hGH[m]) has been shown to increase lean body mass and body weight and to improve physical performance and quality of life in adults with AIDS wasting. The aim of this preliminary study was to evaluate acceptability, tolerance and efficacy of daily subcutaneous injection of r-hGH[m] in 6 children with HIV-associated failure to thrive. Study design: Main inclusion criteria were HIV positivity, age over 6 and under 15 yrs, height velocity below 2 SD for chronological age, anti-retroviral therapy for more than 1 mo, GH peak s 10 ng/mL Children could receive enteral tube feeding which had to be introduced for at least one month and well tolerated. Children were treated for 28 days with r-hGH[m] 0.2 IUlkgld (0.067 mglkgl d). After the study period, each child was offered on-going therapy with rhGH [m] Outcome parameters included fat-free mass (determined by bioelectrical impedance analysis), weight, CD4 count, HIV RNA, IGF-1 and IGF-BPS. Results: At time of analysis, 5 children (F/M: 3/2; ages: 8, 11,14, 10, 12 yrs) have completed the 28 day study. Three were receiving enteral tube feeding. During the study period, mea” fat-free mass and weight gain were + I. 19 and +0.87 kg, respectively ; r-hGH[m] was well tolerated and no increase in viral load occurred. At the end of the study period, all of the children wanted to continue r-hGH[ m] treatment, giving evidence of good acceptability of the treatment. Data on 6 children, with results from the follow-up period will be presented. Conclusion: These preliminary data of r-hGH[m] treatment for HIV infected children are consistent with those described in adults. All children accepted daily injections of r-hGH [ml. Due to entry criteria, only children with advanced failure to thrive were included in this study. A comparative study is warranted, and should involve children at an earlier stage of disease.