Managing Children Living with HIV/AIDS
Subtopic:
HIV treatment
Treatment Modalities of HIV/AIDS
| Treatment Modality | Description |
| Antiretroviral Therapy (ART) | Involves medications that significantly reduce the amount of HIV in the body (viral load) to very low or undetectable levels. Improves health, reduces illness and death, and prevents transmission. |
| Treatment of Acute Bacterial Infections | Focuses on addressing any immediate bacterial infections that may occur in individuals with HIV. |
| Prophylaxis and Treatment of Opportunistic Infections | Involves preventative measures and treatments for infections that take advantage of a weakened immune system due to HIV. |
| Maintenance of Good Nutrition | Ensuring proper dietary intake is crucial for maintaining overall health and supporting the immune system in people living with HIV. |
| Immunization | Administering vaccines to protect against opportunistic infections that individuals with compromised immune systems are more susceptible to. |
| Management of AIDS-Defining Illnesses | Addresses the specific and serious conditions that are characteristic of advanced HIV infection (AIDS). |
| Psychological Support for the Family | Providing emotional, mental health, and practical support to the families of individuals affected by HIV/AIDS. |
| Palliative Care for the Terminally Ill | Provides comfort, symptom management, and support for patients who are in the advanced stages of the illness and nearing the end of life. |
ANTIRETROVIRAL DRUG TREATMENT
| Topic | Description |
| The goal of ART | The primary aim is to suppress the amount of virus in the bloodstream to a level where it is no longer detectable by standard tests. This significantly improves health, decreases the likelihood of illness and death, and prevents onward transmission of the virus. |
| When to Initiate ARV: | ART should be started for all infants diagnosed with HIV before 12 months of age. Also recommended for individuals with clinical AIDS and those with mild to moderate symptoms along with signs of a weakened immune system. |
| Process of Starting ART: | Before starting, assess for opportunistic infections, especially tuberculosis (TB) and cryptococcal meningitis. Treat these first before ART. For others, ART can be offered same-day (“opt-out”). Assess readiness. If ready, start ART that day. If not, plan to start within 7 days for children/pregnant women, and 1 month for adults. |
| Principles for selecting the ARV regimens | Consider lower toxicity, better palatability and fewer pills, effectiveness and durability, allowing for other drug options for second-line treatment, consistency across ages/populations, cost-effectiveness, and establishing a standard treatment for most people with HIV. |
Available ARVs in Uganda
| Drug Class | Examples |
| Nucleoside Reverse Transcriptase Inhibitors (NRTIs): | Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC) |
| Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): | Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV) |
| Integrase Inhibitors: | Dolutegravir (DTG), Raltegravir (RAL) |
| Protease Inhibitors (PIs): | Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV) |
| Entry Inhibitors: | Enfuvirtide (T-20), Maraviroc |
Uses of ART (Antiretroviral Therapy)
Treatment of HIV/AIDS: ART serves as the cornerstone treatment for managing HIV/AIDS. It effectively controls the amount of virus in the body (viral load) and helps maintain a healthy immune system.
Prevention of Mother-to-Child Transmission (PMTCT): ART plays a vital role in preventing the transmission of HIV from a mother living with HIV to her child during pregnancy, the birthing process, and through breastfeeding.
Post-Exposure Prophylaxis (PEP): ART is utilized as an emergency measure for individuals who might have been exposed to HIV. To be effective, it needs to be initiated within 72 hours following the potential exposure.
Pre-Exposure Prophylaxis (PrEP): ART medications can be taken by individuals who do not have HIV but are at higher risk of contracting it. This proactive approach helps prevent HIV acquisition, particularly for those in relationships with HIV-positive partners.
Treatment and Support for Children: Providing children with HIV access to ART is critical for their healthy growth, proper development, and overall long-term well-being. Consistent adherence to the prescribed medication schedule is essential for the treatment to be effective.
Reducing Viral Load to Undetectable Levels: A key benefit of ART is its ability to lower the amount of HIV in the body to levels that are so low they cannot be detected by standard tests. This dramatically reduces the risk of transmitting the virus to others and significantly improves the individual’s health.
Improving Quality of Life: Effective ART treatment leads to a better quality of life for individuals living with HIV. It does this by decreasing the occurrence of opportunistic infections and other health problems related to HIV.
Increasing Life Expectancy: Studies have demonstrated that ART significantly increases the lifespan of individuals living with HIV, allowing them to live longer and healthier lives.
Preventing Sexual Transmission of HIV: By suppressing the viral load to an undetectable level, ART effectively prevents the sexual transmission of HIV. This strategy is often referred to as “treatment as prevention” (TasP).
Reducing HIV-Related Stigma and Discrimination: When ART is successful, it helps to lessen the stigma and discrimination associated with HIV. Individuals can live healthy and productive lives, contributing to a shift in public perception about the disease.
Managing Co-Infections: ART can assist in the management of other infections that are common in people living with HIV, such as hepatitis B and C, and tuberculosis.
Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children
It’s important to note that guidelines for managing HIV are continuously updated based on the latest scientific evidence and public health policies. Therefore, it is crucial to always consult the most recent official guidelines for the most current recommendations. As of the 2022 guidelines, DOLUTEGRAVIR (DTG), an integrase inhibitor, is recommended as the main (anchor) antiretroviral drug in the preferred first and second-line treatment plans for all individuals infected with HIV. This includes children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls, and women who could potentially become pregnant).
| Patient Category | Preferred Regimens | Alternative Regimens |
| Adults and Adolescents | ||
| Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg) | TDF + 3TC + DTG | – If DTG is contraindicated: TDF + 3TC + EFV400 – If TDF is contraindicated: TAF + FTC + DTG – If TDF or TAF is contraindicated: ABC + 3TC + DTG – If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r |
| Children | ||
| Children ≥20Kg – <30Kg | ABC + 3TC + DTG | – If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) – If ABC and TAF are contraindicated: AZT + 3TC + DTG |
| Children <20Kg | ABC + 3TC + DTG | – If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules – If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r |
Note:
Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg. TAF can be used in subpopulations with bone density anomalies. Children will be assessed individually for their ability to correctly take the different formulations of LPV.
Notes from Ministry of Health
Fixed-Dose Combination for ABC-3TC-DTG: For individuals on a regimen consisting of Abacavir, Lamivudine, and Dolutegravir who weigh over 25 kg, it is recommended to use a single pill that combines all three medications (Abacavir/Lamivudine/Dolutegravir 600/300/50 mg). This is instead of taking separate pills of Abacavir/Lamivudine and Dolutegravir. This simplifies the medication intake.
Using Separate ABC/3TC Pills: For patients on regimens like ABC-3TC-ATV/r (Abacavir, Lamivudine, Atazanavir/ritonavir), ABC-3TC-LPV/r (Abacavir, Lamivudine, Lopinavir/ritonavir), and ABC-3TC-DRV/r (Abacavir, Lamivudine, Darunavir/ritonavir), it is advised to use the individual pills of Abacavir/Lamivudine at a dosage of 600/300 mg.
Single-Pill Dolutegravir for AZT-Based Regimens: For individuals whose regimen is based on Zidovudine, Lamivudine, and Dolutegravir (AZT-3TC-DTG), the recommendation is to use a single pill containing 50 mg of Dolutegravir.
Optimizing to Dolutegravir: Patients who are currently eligible and are on regimens containing Atazanavir/ritonavir (ATV/r) or Lopinavir/ritonavir (LPV/r) should be switched to a regimen that includes Dolutegravir, as it is generally preferred.
Preferred PrEP Regimen: While guidelines may offer options for Pre-Exposure Prophylaxis (PrEP) using either Tenofovir Disoproxil Fumarate/Lamivudine (TDF/3TC) or Tenofovir Disoproxil Fumarate/Emtricitabine (TDF/FTC), the recommended approach for programmatic implementation is to use TDF/FTC 300/200 mg for PrEP.
RECOMMENDED FIRST-LINE REGIMEN FOR INITIATION OF ART IN CHILDREN UNDER 3 YEARS OF AGE
Recommended first-line regimen: ABC+3TC+LPV/r (Abacavir + Lamivudine + ritonavir-boosted Lopinavir)
All children under the age of 3 years who are diagnosed with HIV should start their antiretroviral therapy with a combination of Abacavir, Lamivudine, and Lopinavir that is boosted with Ritonavir. This is the preferred initial treatment.
NB: Starting with an LPV/r-based regimen, instead of one based on Nevirapine (NVP), has been shown to result in a lower risk of treatment discontinuation, virological failure (the treatment not working to suppress the virus), or death in children younger than 36 months. Additionally, surveillance data in Uganda has indicated high levels of drug resistance to NNRTIs (like Nevirapine) among children under 18 months who acquired HIV from their mothers. Lopinavir/ritonavir is known to be more resilient to resistance.
When to use alternative first-line regimens AZT+3TC+LPV/r
The combination of Zidovudine (AZT), Lamivudine (3TC), and Lopinavir/ritonavir (LPV/r) should only be considered for children who have a hypersensitivity reaction to Abacavir (ABC). However, such reactions are uncommon in African populations.
WHAT REGIMEN TO SWITCH TO (SECOND-LINE AND THIRD-LINE ART)
Second-line ARVs in adolescents/children above 10 years
Recommended 2nd line regimen: 2 NRTIs + ATV/r (two Nucleoside Reverse Transcriptase Inhibitors plus ritonavir-boosted Atazanavir)
Adolescents and children older than 10 years who need to switch to second-line ART should begin a regimen consisting of two NRTIs and Atazanavir boosted with Ritonavir. The specific NRTIs chosen will depend on the medications the patient was previously taking.
The recommended sequence for NRTIs is:
If the first-line regimen was based on TDF + 3TC (Tenofovir Disoproxil Fumarate + Lamivudine) or ABC+3TC (Abacavir + Lamivudine), the second-line regimen should use AZT+3TC (Zidovudine + Lamivudine).
If the first-line regimen was based on AZT+3TC, the second-line regimen should use TDF + 3TC.
When to use alternative 2nd line regimen: 2 NRTIs + LPV/r
Using Lopinavir/ritonavir (LPV/r) as part of the second-line regimen is primarily for adolescents and children who weigh less than 40kg.
Second-line ARVs in children aged 3 years to less than 10 years
RECOMMENDED 2nd line REGIMEN: 2 NRTIs + LPV/r (two Nucleoside Reverse Transcriptase Inhibitors plus ritonavir-boosted Lopinavir)
Children between 3 and 10 years old who need second-line ART should start a regimen with two NRTIs and Lopinavir boosted with Ritonavir. The preferred formulation is the LPV/r 100/25mg tablet. The choice of NRTIs will be based on the child’s previous treatment.
The recommended sequence of NRTIs is:
If the child’s first-line regimen was ABC+3TC, the second-line should use AZT+3TC.
If the child’s first-line regimen was AZT+3TC, the second-line should use ABC+3TC.
Second-line ARVs in children under 3 years
Recommended 2nd line regimen: 2 NRTIs + RAL (two Nucleoside Reverse Transcriptase Inhibitors plus Raltegravir)
Children younger than 3 years requiring second-line ART should be started on a regimen containing two NRTIs and Raltegravir (RAL). The specific NRTIs will be chosen based on the child’s prior treatment.
The recommended sequence of NRTIs is:
If the first-line regimen was ABC+3TC, the second-line should use AZT+3TC.
If the first-line regimen was AZT+3TC, the second-line should use ABC+3TC.
The rationale for using raltegravir
Raltegravir is the preferred second-line drug for children who have previously been exposed to protease inhibitors. This is because there is a lack of safety and efficacy data for Dolutegravir in children under six years old, and Darunavir is not recommended for this age group.
When to use alternative 2nd line regimen: 2 NRTIs + LPV/r
Using Lopinavir/ritonavir (LPV/r) as an alternative is recommended for children whose first-line regimen included an NNRTI like Nevirapine (NVP).
Monitoring of ARV Treatment
The monitoring of patients receiving antiretroviral therapy (ART) has several important goals:
Assess Response to ART and Diagnose Treatment Failure: Monitoring helps determine if the ART is effectively suppressing the virus and to identify if the treatment is no longer working.
Ensure Safety of Medicines: Identify Side Effects and Toxicity: Regular monitoring helps in detecting any adverse effects or toxicities caused by the ART medications.
Evaluate Adherence to ART: Monitoring can provide insights into how consistently a patient is taking their medication as prescribed.
Methods of Monitoring ARV Treatment
Clinical Monitoring: This involves taking the patient’s medical history and performing a physical examination to assess their overall health and any potential issues.
Laboratory Monitoring: This involves using various laboratory tests to assess the patient’s condition.
Viral Load Monitoring: This is the preferred method for checking how well the ART is working and to diagnose if the treatment is failing. It measures the amount of HIV virus in the blood.
CD4 Monitoring: This measures the number of CD4 cells (a type of immune cell) and is recommended in specific situations.
Other Minor Laboratory Tests: These are additional tests used for specific reasons based on the individual patient’s needs.
Viral Load Monitoring
This is the preferred way to monitor how well ART is working. A patient who has been on ART for more than 6 months and whose treatment is effective should have a suppressed viral load, meaning less than 1000 copies of the virus per milliliter of blood (VL <1000 copies/ml). This is true whether the blood sample is taken as dried blood spots (DBS) or plasma.
Viral load monitoring offers:
An early and more accurate sign that the treatment is failing, indicating a need to switch to second-line drugs. This helps to limit the development of drug resistance and improves patient outcomes.
The ability to distinguish between treatment failure (the drugs are not working) and non-adherence (the patient is not taking the drugs consistently).
The recommended frequency for viral load monitoring is every six months for children and adolescents under 19 years of age.
CD4 Monitoring
Obtaining a baseline CD4 count (the initial measurement) is crucial for determining the risk of opportunistic infections, which are infections that take advantage of a weakened immune system.
CD4 monitoring is recommended for patients who have a high viral load or show signs of advanced HIV disease.
Other Laboratory Tests
| Test | Indication |
| CrAg | Screen for cryptococcal infection |
| Complete Blood Count (CBC) | Assess anaemia risk |
| TB Tests | Suspected tuberculosis |
| Serum Creatinine | Assess kidney function |
| ALT, AST | Evaluate liver function |
| Lipid Profile, Blood Glucose | Assess metabolic health |
Problems Associated with ARV Treatment
Immune Reconstitution Inflammatory Syndrome (IRIS)
IRIS is a collection of signs and symptoms that arise due to the recovering immune system after starting Antiretroviral Therapy (ART). This immune recovery can sometimes overreact to previously present infections. It’s seen in about 10% to 30% of people starting ART, typically appearing within the first 4 to 8 weeks of treatment.
Serious Forms: The most serious instances of IRIS tend to occur in individuals who also have other infections, such as Tuberculosis (TB), Cryptococcal infection, Kaposi’s sarcoma, or herpes zoster (shingles).
Risk Factors: Factors that increase the risk of developing IRIS include having a very low count of CD4+ immune cells (less than 50 cells/mm3) when starting ART, and having opportunistic infections that have spread throughout the body.
Management: IRIS is often temporary and resolves on its own. Management focuses on treating any accompanying infections to lessen the symptoms. It’s important to reassure patients about the condition and emphasize the need to continue taking their ART as prescribed.
Steps to Reduce IRIS Development
Early HIV Diagnosis: Starting ART earlier, before the CD4 cell count drops significantly (below 200 cells/mm3), can help reduce the risk of IRIS.
Optimal Management of Opportunistic Infections: Identifying and treating any existing infections, particularly TB and cryptococcal infection, before beginning ART can be crucial in preventing IRIS.
ARV Drug Toxicity
Range of Toxicities: Antiretroviral (ARV) drugs can have side effects that range from minor discomfort to severe, life-threatening reactions.
Challenges: It can be difficult to determine whether symptoms are due to the ARV medication itself or are a result of complications from the HIV infection.
Management: Healthcare providers should check patients for potential side effects during every clinic visit. The appropriate response will depend on how severe the side effects are.
Management of ARV Side Effects/Toxicities
| Category | Action |
| Severe, Life-threatening Reactions (e.g., SJS/TEN, severe hepatitis) | – Discontinue all ARVs immediately. – Manage the medical event and substitute offending drug when stable. |
| Severe Reactions (e.g., Hepatitis and Anemia) | – Substitute offending drug without stopping ART. |
| Moderate Reactions (e.g., Gynaecomastia, Lipodystrophy) | – Substitute with a drug in the same class or different class with a different toxicity profile. – Do not discontinue ART; continue if feasible. |
| Mild Reactions (e.g., Headache, Minor Rash, Nausea) | – Do not discontinue or substitute ART. – Provide reassurance and support to mitigate adverse reactions. – Counseling about the events. |
Management of HIV-Positive Pregnant Mothers
Key Interventions for Preventing Mother-to-Child Transmission (eMTCT):
Routine HIV Counseling and Testing during Antenatal Care (ANC): Offer HIV testing and counseling at the first antenatal care visit. If the initial test is negative, repeat the HIV test during the third trimester or at the time of labor.
Enrollment in HIV Care: If a pregnant woman tests positive for HIV and is not already receiving treatment, enroll her in HIV care services.
Viral Load and Continued ART: For mothers already on Antiretroviral Therapy (ART), assess their viral load and ensure they continue their current medication regimen.
Lifelong ART (Option B+): Implement Option B+, which involves starting and continuing ART for life for all pregnant and breastfeeding women living with HIV, initiated during pregnancy, labor, and the postpartum period.
Recommended ARV Regimen for Option B+: The preferred regimen is a once-daily, fixed-dose combination (FDC) pill containing Tenofovir Disoproxil Fumarate (TDF), Lamivudine (3TC), and Efavirenz (EFV). This should be started early in pregnancy, regardless of the CD4 cell count, and continued throughout labor, delivery, and for the woman’s lifetime.
Alternative Regimens: For women who cannot tolerate the recommended regimen:
If TDF is contraindicated: Abacavir (ABC) + 3TC + EFV
If EFV is contraindicated: TDF + 3TC + Atazanavir boosted with Ritonavir (ATV/r)
Safety of TDF and EFV: Both TDF and EFV are considered safe for use during pregnancy.
New Diagnoses During Labor: Women newly diagnosed with HIV during labor will start Highly Active Antiretroviral Therapy (HAART) for life after giving birth.
Prophylaxis for Opportunistic Infections:
Cotrimoxazole: Prescribe a daily tablet of Cotrimoxazole 960 mg throughout pregnancy and the postpartum period. Mothers taking Cotrimoxazole do not need Intermittent Preventive Treatment in pregnancy (IPTp) with Sulfadoxine-Pyrimethamine (SP) for malaria prevention.
Care of HIV-Exposed Infants:
Mother-Baby Care Point: HIV-exposed infants should receive care alongside their mothers at a designated mother-baby care point until the infant is 18 months old. These facilities provide comprehensive services for both the infant and parent(s).
Goals of HIV-Exposed Infant Care:
Prevent HIV infection in the infant.
Diagnose HIV infection early in infants who do become infected.
Provide child survival interventions to prevent deaths from preventable childhood illnesses.
Recommended Health Facility Visits: HIV-exposed infants and their mothers should attend at least nine scheduled visits to the health facility during the first 18 months of the infant’s life (at 6, 10, and 14 weeks, then at 5, 6, 9, 12, 15, and 18 months).
Nevirapine Prophylaxis:
Administer Nevirapine (NVP) syrup to the infant from birth for 6 weeks.
Extend NVP prophylaxis to 12 weeks for infants at high risk of HIV infection. High-risk infants include those who are breastfeeding and whose mothers:
Started ART less than 4 weeks before delivery.
Had a viral load greater than 1000 copies/mL within 4 weeks before delivery.
Were diagnosed with HIV during the third trimester or while breastfeeding (postnatally).
Diagnostic Testing and Follow-up:
Perform a Polymerase Chain Reaction (PCR) test for HIV at 6 weeks of age (or at the first encounter after this age). Begin Cotrimoxazole prophylaxis at this time.
If the PCR test is positive, start the infant on ART and Cotrimoxazole. Repeat the PCR test for confirmation.
If the initial PCR is negative and the baby has never been breastfed, the child is confirmed HIV-negative. Stop Cotrimoxazole prophylaxis, continue routine clinical monitoring, and perform an HIV serology test at 18 months.
If the PCR is negative but the baby has breastfed or is currently breastfeeding, start or continue Cotrimoxazole prophylaxis and repeat the PCR test 6 weeks after breastfeeding has stopped.
Follow up with all HIV-exposed infants and perform a PCR test if the child develops any clinical symptoms suggestive of HIV at any point, regardless of previous negative test results.
For infants who remain negative, perform an HIV serology test at 18 months before final discharge from care.
Dosages of Nevirapine
| Age Group | Weight Range | Dosage | Syrup Volume (10 mg/ml) |
| Child 0-6 weeks | 2 – 2.5 Kg | 10 mg once daily | 1 ml |
| Child 0-6 weeks | > 2.5 Kg | 15 mg once daily | 1.5 ml |
| Child 6-12 weeks | Any weight | 20 mg once daily | 2 ml |
Cotrimoxazole Prophylaxis: All infants born to mothers with HIV should receive daily cotrimoxazole starting at 6 weeks of age. This medication should continue until it’s confirmed that the child is not infected with HIV.
Child weighing less than 5 kg: 120 mg once daily.
Child weighing between 5 and 14.9 kg: 240 mg once daily.
Isoniazid (INH) Preventive Therapy (IPT):
Infants exposed to HIV who also have been exposed to Tuberculosis (TB) should receive Isoniazid for six months to prevent TB infection. The daily dosage is 10 mg of Isoniazid per kilogram of the child’s weight, along with 25 mg of pyridoxine. However, if a newborn’s mother has TB and has been taking anti-TB medications for at least two weeks before giving birth, the infant does not require INH prophylaxis.
Immunization:
Children exposed to HIV should receive vaccinations according to the standard national immunization schedule. If the BCG vaccine (for tuberculosis) was missed at birth, it should not be given if the child is showing symptoms of HIV. The yellow fever vaccine should be avoided in children with symptomatic HIV. The measles vaccine can be safely administered even to children who have symptomatic HIV.
Counseling on Infant Feeding Choice:
It is crucial to discuss infant feeding options with mothers living with HIV, explaining the potential risks and benefits of each choice. Highlight the risk of HIV transmission through breastfeeding (approximately 15%), but also the risks associated with not breastfeeding, such as malnutrition and diarrhea. Emphasize that mixed feeding (combining breastfeeding with formula or other foods) can increase the risk of both HIV transmission and diarrhea.
Provide clear information about the available feeding options, outlining the advantages and disadvantages of each. Support the mother in evaluating her choices, making an informed decision about the best option for her and her baby, and then provide ongoing support for her chosen method.
Feeding Options:
Recommended Option: Exclusive breastfeeding for the first six months, followed by the introduction of appropriate complementary foods while continuing breastfeeding.
Cessation of Breastfeeding: Exclusive breastfeeding can be stopped between 3 and 6 months if replacement feeding becomes a feasible option after this period. If replacement feeding is started early, breastfeeding must be completely discontinued.
Replacement Feeding: This involves feeding the baby with properly prepared home-based formula or commercial infant formula, followed by appropriate family foods. This option is suitable if it is acceptable, feasible, safe, and sustainable (affordable) for the mother.
If the Mother Chooses Breastfeeding:
Explain strategies to minimize the risk of HIV transmission through breastfeeding. Maintaining good breast health is essential, as conditions like mastitis and cracked nipples can increase the risk of transmission. Advise exclusive breastfeeding for the first 3 to 6 months.
If the Mother Chooses Replacement Feeding:
Provide thorough counseling and education on the safe preparation of formula, emphasizing hygiene, correct amounts, and appropriate feeding times. Schedule a follow-up visit within a week of the baby’s birth and at any subsequent visits to the health facility to provide ongoing support and address any questions or concerns.
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