Kids can be picky eaters even in the best situations. I’ve long thought a useful invention would be a machine that chews up food and extrudes it in the form of Cheerios or hot dogs. But when a child is struggling with the strains and pains of HIV, dietary difficulties can be especially overwhelming. Since no two children are the same, parents, caregivers and nutritionists should assess daily nutritional needs on a case-by-case basis.

To the hard-enough task of designing a balanced diet, HIV adds the muddle of medications and opportunistic diseases. Marcy Fenton, nutrition advocate at AIDS Project Los Angeles (APLA), says: “A chronic HIV infection, which causes greater than normal nutritional demands, is laid on top of the child’s natural growing process. Add episodes of new infection, and you’re facing major hurdles.”

There are two main causes of nutritional problems in children with HIV. The first is physiological: Disease processes or drugs can interfere with the absorption or retention of nourishment. Diarrhea, nausea and wasting are the most common culprits. Every drug has its particular effect on taste and appetite, and some ailments require specific nutritional adaptation. Renal problems, say, call for reduced protein intake. Certain complaints -- thrush for example -- can make it simply too painful to eat. Your physician and a registered dietician are the best resources for such difficulties.

The second cause is psychological. The intimidating presence of doctors, needles and feeding tubes as well as the restrictions on freedom and the separation from families imposed by hospital stays -- daunting obstacles for many adults -- can be crushing for a child. “Children with HIV are often depressed for many reasons,” says Maria Baldo, child-life nutritionist at Gay Men’s Health Crisis (GMHC). “Feeling tired and not being able to play like other kids, for instance, are common problems. And many of these kids have also lost their parents to this disease. When we are looking for the cause of a lack of appetite, we often don’t realize it can be depression.”

So how to deal with an HIV positive child who either cannot or will not eat? “These are children who, more than any healthy child, have their power taken away from them. It becomes more important to empower the child as much as possible: Invite their participation in shopping, make them a part of food preparation,” suggests Baldo. As a kind of absolution for frustrated caregivers, she offers, “Your responsibility starts and ends with getting nutrition on the plate. You can’t force your child to eat. And you shouldn’t.”

Nutrition is playing an increasingly important role in HIV treatment, although it remains underfunded and understudied. And with scientists’ longstanding failure to adequately research children’s issues, the information that does exist is relevant mainly to adults. “Nutritional information should be an integral part of medical care for both adults and children. People with HIV need much more than the standard measurements of lean body mass -- they need guidance on a wide range of dietary issues,” says APLA’s Fenton. “Equally important is to develop strategies to prevent the weight loss many experience during hospital stays.”

Dr. Mary Romeyn, author of Nutrition and HIV (Jossey-Bass/San Francisco), states that a vigilant, aggressive stance toward HIV involves maintaining a high level of nutrition. “It is critical to fight the virus with antivirals and treat infections early,” she says. “But wasting begins well before it is detected, so we need to be sure that kids get enough calories, protein and vitamin supplements right from the start. Data continue to support a direct correlation between high levels of antioxidants and lowered levels of virus.”

As a practical measure, Romeyn suggests indulging a child’s cravings and offering comfort foods. “Be sure to have them around so they’re ready when you need them,” she says. “If your child’s comfort food is pudding [see recipe below], desire for it might pass by the time you get it made. Keep it in the refrigerator.” When pressed, Romeyn reverts to form. “I’m a mother and a grandmother,” she says. “I can’t help believing the most important food these children can have is food that says to them, ’Your mother loves you.’”

ZESTY APPLE RICE PUDDING

3/4 cup Basmati rice
1/4 cup dried currants or raisins
1 teaspoon cinnamon
1 dash ground cloves
1 3/4 cup whole milk (or soy milk)
2 medium apples, peeled, cored and sliced
1/2 cup unsweetened apple juice
1 tablespoon maple syrup
2 teaspoons fresh lemon juice
1 tablespoon lemon peel
1 teaspoon vanilla
1 cup diced strawberries or other fresh berry

1. Over a medium-high heat simmer the rice, currants, cinnamon, cloves and milk. Cook until all the milk is absorbed (about 30 minutes). Transfer to a mixing bowl and let cool.

2. In a separate saucepan combine the apples and apple juice. Simmer uncovered until the apples are soft and the liquid is reduced to about two tablespoons. Cool and transfer to food processor.

3. Add maple syrup, lemon juice, vanilla and lemon peel. Pulse into applesauce. Fold into the rice. Serve in small bowls topped with berries.

Yield: 4 servings