OpiniãoNutrition assessment and counselling
- All individuals with active TB should receive (i) an assessment of their nutritional status and (ii) appropriate counselling based on their nutritional status at diagnosis and throughout treatment (strong recommendation, no evidence).
Management of severe acute malnutrition
- School-age children and adolescents (5 to 19 years), and adults, including pregnant and lactating women, with active TB and severe acute malnutrition should be treated in accordance with the WHO recommendations for management of severe acute malnutrition (2) (strong recommendation, very low quality evidence).
- Children who are less than 5 years of age with active TB and severe acute malnutrition should be treated in accordance with the WHO recommendations for the management of severe acute malnutrition in children who are less than 5 years of age (3) (strong recommendation, very low quality evidence).
Management of moderate undernutrition
- School-age children and adolescents, and adults, including lactating women, with active TB and moderate undernutrition, who fail to regain normal BMI after two months’ TB treatment, as well as those who are losing weight during TB treatment, should be evaluated for adherence and comorbid conditions. They should also receive nutrition assessment and counselling, and, if indicated, be provided with locally available nutrient-rich or fortified supplementary foods, as necessary to restore normal nutritional status (2) (conditional recommendation, low quality evidence).
- Children who are less than 5 years of age with active TB and moderate undernutrition should be managed as any other children with moderate undernutrition. This includes provision of locally available nutrient-rich or fortified supplementary foods, in order to restore appropriate weight-for-height (4) (strong recommendation, very low quality evidence).
- Pregnant women with active TB and moderate undernutrition, or with inadequate weight gain, should be provided with locally available nutrient-rich or fortified supplementary foods, as necessary to achieve an average weekly minimum weight gain of approximately 300 g in the second and third trimesters (strong recommendation, very low quality evidence).
- Patients with active MDR-TB and moderate undernutrition should be provided with locally available nutrient-rich or fortified supplementary foods, as necessary to restore normal nutritional status (strong recommendation, very low quality evidence).
Micronutrient supplementation
- A daily multiple micronutrient supplement at 1× recommended nutrient intake should be provided in situations where fortified or supplementary foods should have been provided in accordance with standard management of moderate undernutrition (2, 4), but are unavailable (conditional recommendation, very low quality evidence).
- All pregnant women with active TB should receive multiple micronutrient supplements that contain iron and folic acid and other vitamins and minerals, according to the United Nations Multiple Micronutrient Preparation (5), to complement their maternal micronutrient needs (conditional recommendation, very low quality evidence).
- For pregnant women with active TB in settings where calcium intake is low, calcium supplementation as part of antenatal care is recommended for the prevention of pre-eclampsia, particularly among those pregnant women at higher risk of developing hypertension, in accordance with WHO recommendations (6, 42) (strong recommendation, moderate quality evidence).
- All lactating women with active TB should be provided with iron and folic acid and other vitamin and minerals, according to the United Nations Multiple Micronutrient Preparation (5), to complement their maternal micronutrient needs (conditional recommendation, very low quality evidence).
Contact investigation
- In settings where contact tracing is implemented, household contacts of people with active TB should have a nutrition screening and assessment as part of contact investigation. If malnutrition is identified, it should be managed according to WHO recommendations (2–4) (conditional recommendation, very low quality evidence).
Remarks
- Nutritional assessment is an essential prerequisite to the provision of nutritional care.
- There is no evidence to recommend that nutritional management of severe acute malnutrition should be different for those with active TB than for those without active TB.
- There is no evidence to recommend that nutritional management of severe acute malnutrition should be different in children with active TB than for those without active TB.
- Concerns about weight loss or failure to gain weight should trigger further clinical assessment (e.g. resistance to TB drugs, poor adherence, comorbid conditions) and nutrition assessment of the causes of undernutrition, in order to determine the most appropriate interventions.
- Closer nutritional monitoring and earlier initiation of nutrition support (before the first 2 months of TB treatment are completed) should be considered if the nutritional indicator is approaching the cut-off value for a diagnosis of severe acute malnutrition.
- There is no evidence to recommend that nutritional management of moderate undernutrition should be different for children (less than 5 years of age) with active TB than for those without.
- Efforts should be made, within the sound principles of nutrition assessment, counselling and support, to ensure that TB patients are receiving the recommended intake of micronutrients, preferably through food or fortified foods. If that is not possible, micronutrient supplementation at 1× the recommended nutrient intake is warranted.
- There is insufficient evidence to recommend that antenatal supplementation of calcium, iron and folic acid should be any different for pregnant women with active TB than for those without TB. However, since pregnant and lactating women with HIV have improved maternal and birth outcomes when taking a multiple micronutrient supplement, pregnant women with TB were considered comparable to those with HIV in their potential benefit from having a multiple micronutrient supplement.
- If pregnant or lactating women with moderate undernutrition are receiving a fortified supplementary food product, then the micronutrient content of this product will have to be taken into account when considering a multiple micronutrient supplement, in order to avoid over-supplementation of micronutrients.
- Screening for malnutrition, especially in children who are less than 5 years of age, is recommended at all health-care encounters and this should include contact investigation of TB.