II. Epidemiology
- Definitions
- Pediatric refers to under age 13
- Pediatric HIV Prevalence
- World: 2.5 Million
- United States: 10,834 (in 2009)
- Universal screening and management protocols for HIV in Pregnancy have kept these numbers low in United States
- Pediatric HIV due to perinatal transmission is now less than 200/year in United States
- Pediatric AIDS Prevalence
- Worldwide: 1 million
- United States: 6611
- Mortality
- AIDS is the leading cause of death in ages 1-4
III. Pathophysiology: Common modes of transmission (acquisition)
- Hemophilia
- Transfusion (risk of 1 in 425,000 by HIV ELISA test)
- Foreign adoptee
-
Perinatal HIV Transmission
- Accounts for 90% of cases under age 13 years
- Adolescents with high risk behaviors
- Accounts for 50% of new HIV cases in the United States under age 18 years
IV. Clinical Manifestations
-
Generalized Lymphadenopathy
- Lymph nodes may be size of Lymphoma nodes
- Hepatosplenomegaly
- Recurrent Candidiasis (especially Thrush over age 2 years old)
- Chronic Diarrhea or Recurrent Diarrhea
- Developmental Delay
- Encephalopathy
- Failure to Thrive
- Lymphocytic Interstitial Pneumonitis (LIP)
-
Pneumocystis carinii Pneumonia
- May be first indicator of perinatal HIV Infection
- Peak Incidence at age 3 to 6 months
- May occur regardless of CD4 Count
V. Labs: Diagnosis with HIV detection
-
HIV ELISA and HIV Western Blot are unreliable <18 month
- IgG to HIV acquired transplacentally
- Every infant born to an HIV infected mother will test positive for HIV Antibody
- HIV Antibody isappears in 98% infants by 18 months
- Child under age 18 months
- Protocol
- Birth (within first 48 hours)
- Obtain 2 separate blood samples (not cord blood)
- Age 1 to 2 months
- Age 4 to 6 months
- Birth (within first 48 hours)
- HIV virus culture
- Efficacy: >95% sensitive by 3 months
- Cost: $200
- Blood Culture must be sent same day
- HIV PCR - RNA or DNA, viral load (>95% sensitive by 3 months)
- Cost: $200
- Similar accuracy as HIV virus culture
- HIV Antigen P24 assay
- High Specificity, low sensitivity
- Cost: $35
- Does not rule-out HIV if negative
- Protocol
- Child over age 18 months
- Screening: HIV ELISA
- Confirmation: HIV Western Blot
- Sero-reverter of child born to HIV positive mother
VI. Labs: Other initial findings
- Hypergammaglobulinemia (IgG, IgM, IgA)
- T-Cell Levels: Low CD4 Count and Low CD8 Count
-
Complete Blood Count
- Lymphocytes <10% is a concerning finding
- Low Platelets
- Anemia
- Neutropenia
-
Liver Function Tests
- Elevated transaminases
VII. Labs: Monitoring
- See HIV detection above for HIV PCR protocol
- PPD Skin Testing annually after 12 months
- Complete Blood Count monthly from birth to 4 months
-
CD4 Count at 1 and 3 months
- See T-Cell Levels above for precautions about interpretation in infants and children
VIII. Complications: Changes specific to Pediatric HIV compared to Adult HIV
- Rapid progression (In Utero transmission)
- See HIV in Pregnancy
- Increased Incidence of Encephalopathy
- Failure to Thrive
- Recurrent Bacterial Infection
- Lymphocytic Interstitial Pneumonitis (LIP)
- Decreased Incidence of malignancies
IX. Management: Zidovudine (AZT) (if HIV positive Mother)
- Intrapartum
- See HIV in Pregnancy
- Newborn
- Dose: 2 mg/kg PO q6 hours for 6 weeks
- Begin within 8 hours of delivery
- Monitoring for Anemia
- Follow Complete Blood Count as above
- Mild Anemia peak at 6 weeks, resolves by 12 weeks
- No treatment usually necessary
X. Management: Prophylaxis in HIV positive children
- Immunoglobulin IV
- Mycobacterium Avium Complex (MAC)
-
Pneumocystis carinii prophylaxis
- Agents
- Preferred: Trimethoprim-Sulfamethoxazole (Septra)
- Dose: 5 mg/kg/day of TMP component divided bid
- Lower dose than usual 8 mg/kg/day
- Frequency: Twice daily for 3 days per week
- Alternative agents
- CD4 Count to Start Prophylaxis dependent on age
- Agents
-
Tuberculosis exposure
- Testing
- PPD skin test (positive if 5 mm or greater)
- Chest XRay
- Protocol after Tuberculosis exposure
- Testing
-
Immunizations
- See Immunization in HIV
- Influenza Vaccine at 6 months and then yearly
- Routine Immunizations
- Give IPV instead of OPV
- Varicella Vaccine (if CDC Immune Category I)
- MMR Vaccine (if CDC Immune Category I or II)
XI. Precautions: Acute Illness
- Aggressively manage adolescents with HIV (frequently non-compliant with medication regimens)
- Exercise low threshold for admission for children with HIV and a low age-adjusted CD4 Count
-
Headache and fever should be evaluated with head imaging and Lumbar Puncture
- See Headache in HIV
XII. Prevention
- Minimize exposure and evaluate infectious contacts
- Prevent opportunistic infection
- Avoid undercooked foods (Salmonellosis)
- Avoid cat litter box exposure (Toxoplasmosis)
- Consider using only bottled or purified water
XIII. Prognosis: Distinct patterns of disease progression
- Rapid (30%)
- Associated with in utero transmission
- Symptom onset in first 6 months of life
- Slower (70%)
- Symptom onset in first 3 years of life
- Adult equivalent (<5%)
- Symptom onset at 10 years of life
XIV. References
- Church and Claudius in Majoewsky (2013) EM:Rap 13(8): 7-8
- (1998) MMWR Morb Mortal Wkly Rep 47(RR-4):1-43 [PubMed]
- Krist (2002) Am Fam Physician 65(10):2049-56 [PubMed]