Infant Nutritional Status
he purpose of this indicator is to monitor the number and proportion
of infants with who are acutely malnourished as exhibited by thinness at approximately 12
months of age. 12 months of age is a critical time to assess the nutrition status of infants as
mothers who elect breastfeeding are transitioning to replacement feeding and complementary
feeding has likely begun. It is at this point that growth faltering tends to occur most rapidly,
and childhood infection is common. Satisfactory nutritional status at this age provides a proxy
for success in transition to replacement feeding and complementary feeding. Tracking
anthropometric data can assist in avoidance of growth faltering, and prevention/management
of infection. It can also serve to inform the development of strategies for nutrition
interventions in care and support services for infants from birth to 12 months of age and
Interpretation. By measuring the level of acute malnutrition among HIV-exposed infants, we
can ascertain whether an infant is malnourished at a critical point in the infants’ development
and growth. Since malnutrition can occur as a consequence of inadequate feeding, inadequate
prevention and/or management of infection, or both, normal nutritional status provides a
reasonable proxy for adequate nutrition and health at this critical point in an infant’s
development. A broader interpretation would allow program managers to ascertain whether or
not nutritional care and support programs for infants are effective. With the roll-out of the
2009 WHO Guidelines on HIV and infant feeding, the 12-month follow up visit will take on
added significance, making this time point a natural fit for measuring infants’ nutritional status
due to the fact that breastfeeding is recommended until at least 12 months of age in many
settings. Finally, by identifying infants who are extremely malnourished or wasted, health care
providers can ask HIV-positive mothers whether or not their infant has been tested for HIV and
then counsel them to do so as needed.
Uses. The indicator can inform program managers and donors about the extent of malnutrition
among infants of PMTCT clients. The indicator can also inform about the extent to which
nutrition services and other PMTCT interventions are leading improvements in infant nutrition
status. At the health facility level, assessing nutritional status can identify infants who may
benefit from supplemental or therapeutic feeding and other nutrition interventions early
enough to avoid severe malnutrition. This indicator may also help identify HIV-affected families
in need of referral to other support services such as food security and livelihood programs.
High prevalence of malnutrition, or increasing prevalence of malnutrition, should prompt
efforts to improve nutritional care and support, and prevention/control of childhood disease
and infection among HIV-exposed infants. Geographic disaggregation will help national decision
makers target efforts to areas where HIV-exposed infants are most vulnerable to malnutrition.
Disaggregation by HIV-status of the infant will help programs better plan for the care and
support needs of this population.
Uses. At the national or program level, this indicator can be used to track progress toward safer
infant-feeding practices among HIV-infected women and their exposed infants, and to assess
the results of infant feeding counseling during the antenatal and peripartum period. The
indicator also contributes to assessment of the quality of counseling on infant feeding (with low
rates of mixed feeding likely to indicate adequate counseling and support).
At the health facility level, the indicator is useful to monitor the extent to which women are
choosing the safest infant feeding practices. Nutrition education efforts could be tailored to
provide women the knowledge to make informed decisions about feeding practices and skills to
feed their infants as safely as possible, regardless of the practice they choose. The indicator can
also be used to help programs or facilities plan for ARV requirements based on the number of
women who are breastfeeding at 3 months.
All HIV-exposed infants attending the 12-month follow up visit who have a weight for height Z-score less than -2SD at any point during the reporting period, or who have a MUAC of < 125 mm at any point during the reporting period
All HIV-exposed infants who attend the 12-month infant follow-up visit during the same period and are assessed for nutritional status
Numerator / Denominator
The primary source of data for this indicator is patient records, which include information about the nutrition status of clients enrolled in care and treatment.
To identify undernourished children 6-59 months, weight-for-height (WFH) z-scores are used. A
z-score allows comparison of a child’s weight-height ratio to that of a reference population of
the same age, requiring data on height, weight, and age of the child. Growth charts may be
used to facilitate data collection and interpretation of z-scores. A child’s weight and height can
be plotted on a pre-printed graph, which allows health care providers to easily identify children
whose z-scores are less than −2.
MUAC is also recommended by WHO as an indicator of severe acute malnutrition among
children 6-59 months. MUAC measures the circumference of the left upper arm in millimeters
(mm). It is taken at a point midway between the tip of the shoulder and the elbow. MUAC is a
proxy measure of nutrient reserves in muscle and fat that are not affected by pregnancy and
are independent of height.
The numerator for this indicator includes all HIV-exposed infants attending the 12-month follow
up visit who have a weight for height Z-score less than -2SD at any point during the reporting
period, or who have a MUAC of < 125 mm at any point during the reporting period.1 The
denominator includes all HIV-exposed infants who attend the 12-month infant follow-up visit
during the same period and are assessed for nutritional status.
In choosing between the two methods of measurement presented above, programs are
encouraged to choose the measurement method (weight-for-height scores or MUAC) that is
most efficient for them to collect, as this will make collection of this indicator more sustainable.
However, this will limit the value of the indicator for cross-program and global comparisons. To
the extent possible, individual programs should ensure that the same measure is used across all
services delivery modes and sites.
Data collection method. The data will be collected from the facility-based HIV Exposed Infant
Register, via the HIV Care/ART Card that stays at facilities (per the Three Interlinked Patient
Monitoring Systems for HIV care/ART, MCT/PMTCT and TB/HIV: Standarized Minimum Data Set
and Illustrative Tools).2 When an infant is brought for his/her 12-month follow up visit, the
nurse also will measure the child’s weight and length (or weight for age, if that is the national
policy) and determine a Z-score using a reference chart, ideally based on the WHO Child
Growth Standards. The nurse will note that the infant’s Z-score is either <-2SD or ≥-2SD. If
using MUAC, the nurse should note whether the infant’s MUAC < 125mm. (yes/no).
At a later point, a health clinic staff member will transcribe the information from the child
health card to the HIV-exposed infant register (similarly to how it is done for the infant feeding
indicator – data are collected at the DPT3 visit, recorded in the card that remains at the clinic
and then transcribed at the end of the day into the HIV-exposed Infant register.)
During the follow-up visit, the nurse will need to identify that the infant is HIV-exposed or
confirmed HIV-positive. In order to do that, the nurse will need to look in the Child Health Card
to see if the mother’s HIV status is noted. Some Child Health Cards contain this information;
however some may not contain maternal HIV status. If the mother’s HIV status is not in the
Child Health Card, the nurse then should ask the mother if she has received an HIV test and
knows her status.
Data for aggregation will be collected from the WHO’s Interlinked Patient Monitoring System
(ILPMS) HIV-exposed infant register.
Frequency of measurement and reporting. These data will be collected and aggregated on a
regular basis, depending on national policy (monthly, quarterly, semi-annually, or annually).
Disaggregation. This indicator will not require disaggregation. However, geographic
disaggregation may help national decision makers target efforts to areas where HIV-exposed
infants are most vulnerable to malnutrition. Additionally, programs that have the wherewithal
to disaggregate by infant HIV-status (confirmed positive/negative) will be able to collect
additional information on the especial vulnerability of HIV-positive infants to malnutrition and
to better identify care and support needs for this population.
HIV status: HIV positive, HIV negative
Strengths: One of the strengths of this indicator is that it measures HIV-exposed infant’s
nutritional status at an important point in overall development and growth. Since nutritional
status is the outcome of both the child’s feeding experience as well as his or her health experience, the prevalence of malnutrition provides an understanding of mortality risk in the
population of HIV-exposed infants.
Weaknesses: This indicator may not reflect the actual distribution of nutritional status of HIV-
exposed infants at the national level as it does not include HIV-exposed infants whose exposure
status is unknown. It is also possible that infants whose caretakers are sick are less likely to be
seen at a health facility for their 12 month follow-up visit. Yet, these may be the infants who are
most vulnerable to malnutrition. Thus, the indicator may underestimate the prevalence of
malnutrition in this group.
While many countries’ reporting systems do allow them to effectively distinguish and report
HIV-exposed infants from non-exposed infants, this remains a challenge in some settings. Either
systems have not evolved to include HIV-exposed infant registers, or where they do exist, they
can engender stigma and discrimination towards HIV-exposed infants and their mothers. For
this reason, care must be taken in the collection of data specifically on HIV-exposed individuals
Resources required. Collection of this indicator requires data collection instruments/registers
that can capture weight-for-height Z scores or MUAC values at the 12 month follow-up visit.
Anthropometric measurement equipment (scales, height boards, MUAC tapes) are also
required. The indicator also requires data collection systems that can effectively identify HIV-
At the level of the health facility, they will also require health personnel who have been trained
in infant anthropometric measurement and recording, whether it is weight-for-height
measurements, or MUAC.
While this specific indicator has not been field-tested, there are plenty of settings in which
weight-for-height z scores or MUAC for infants are routinely collected. Some percentage of
these infants is HIV-positive, and must be marked as such within infant registers. For this
reason, we consider the indicator as effectively field-tested, given the broad and routine scale
on which nutritional assessments on different populations of infants occurs.