Pediatric HIV

Aka: Pediatric HIV, Pediatric AIDS, HIV Related Pediatric Concerns

II. Epidemiology

  1. Definitions
    1. Pediatric refers to under age 13
  2. Pediatric HIV Prevalence
    1. World: 2.5 Million
    2. United States: 10,834 (in 2009)
      1. Universal screening and management protocols for HIV in Pregnancy have kept these numbers low in United States
      2. Pediatric HIV due to perinatal transmission is now less than 200/year in United States
  3. Pediatric AIDS Prevalence
    1. Worldwide: 1 million
    2. United States: 6611
  4. Mortality
    1. AIDS is the leading cause of death in ages 1-4

III. Pathophysiology: Common modes of transmission (acquisition)

  1. Hemophilia
  2. Transfusion (risk of 1 in 425,000 by HIV ELISA test)
  3. Foreign adoptee
  4. Perinatal HIV Transmission
    1. Accounts for 90% of cases under age 13 years
  5. Adolescents with high risk behaviors
    1. Accounts for 50% of new HIV cases in the United States under age 18 years

IV. Clinical Manifestations

  1. Generalized Lymphadenopathy
    1. Lymph nodes may be size of Lymphoma nodes
  2. Hepatosplenomegaly
  3. Recurrent Candidiasis (especially Thrush over age 2 years old)
  4. Chronic Diarrhea or Recurrent Diarrhea
  5. Developmental Delay
  6. Encephalopathy
  7. Failure to Thrive
  8. Lymphocytic Interstitial Pneumonitis (LIP)
  9. Pneumocystis carinii Pneumonia
    1. May be first indicator of perinatal HIV Infection
    2. Peak Incidence at age 3 to 6 months
    3. May occur regardless of CD4 Count

V. Labs: Diagnosis with HIV detection

  1. HIV ELISA and HIV Western Blot are unreliable <18 month
    1. IgG to HIV acquired transplacentally
    2. Every infant born to an HIV infected mother will test positive for HIV Antibody
    3. HIV Antibody isappears in 98% infants by 18 months
  2. Child under age 18 months
    1. Protocol
      1. Birth (within first 48 hours)
        1. Obtain 2 separate blood samples (not cord blood)
      2. Age 1 to 2 months
      3. Age 4 to 6 months
    2. HIV virus culture
      1. Efficacy: >95% sensitive by 3 months
      2. Cost: $200
      3. Blood Culture must be sent same day
    3. HIV PCR - RNA or DNA, viral load (>95% sensitive by 3 months)
      1. Cost: $200
      2. Similar accuracy as HIV virus culture
    4. HIV Antigen P24 assay
      1. High Specificity, low sensitivity
      2. Cost: $35
      3. Does not rule-out HIV if negative
  3. Child over age 18 months
    1. Screening: HIV ELISA
    2. Confirmation: HIV Western Blot
  4. Sero-reverter of child born to HIV positive mother
    1. Assumed child is uninfected when:
      1. ELISA HIV negative >18 months of age
      2. HIV PCR or HIV Culture negative twice
        1. At least one sample must be after 6 months

VI. Labs: Other initial findings

  1. Hypergammaglobulinemia (IgG, IgM, IgA)
  2. T-Cell Levels: Low CD4 Count and Low CD8 Count
    1. T-Cells even at normal levels, function poorly in infants
    2. Pneumocystis Pneumonia can occur despite normal T-Cell levels in infants
    3. CD4 Count of 500 in an infant under age 1 year old is equivalent to an adult with a CD4 Count of 200
  3. Complete Blood Count
    1. Lymphocytes <10% is a concerning finding
    2. Low Platelets
    3. Anemia
    4. Neutropenia
  4. Liver Function Tests
    1. Elevated transaminases

VII. Labs: Monitoring

  1. See HIV detection above for HIV PCR protocol
  2. PPD Skin Testing annually after 12 months
  3. Complete Blood Count monthly from birth to 4 months
  4. CD4 Count at 1 and 3 months
    1. See T-Cell Levels above for precautions about interpretation in infants and children

VIII. Complications: Changes specific to Pediatric HIV compared to Adult HIV

  1. Rapid progression (In Utero transmission)
    1. See HIV in Pregnancy
  2. Increased Incidence of Encephalopathy
  3. Failure to Thrive
  4. Recurrent Bacterial Infection
  5. Lymphocytic Interstitial Pneumonitis (LIP)
  6. Decreased Incidence of malignancies

IX. Management: Zidovudine (AZT) (if HIV positive Mother)

  1. Intrapartum
    1. See HIV in Pregnancy
  2. Newborn
    1. Dose: 2 mg/kg PO q6 hours for 6 weeks
    2. Begin within 8 hours of delivery
    3. Monitoring for Anemia
      1. Follow Complete Blood Count as above
      2. Mild Anemia peak at 6 weeks, resolves by 12 weeks
      3. No treatment usually necessary

X. Management: Prophylaxis in HIV positive children

  1. Immunoglobulin IV
  2. Mycobacterium Avium Complex (MAC)
    1. Clarithromycin
    2. Azithromycin
  3. Pneumocystis carinii prophylaxis
    1. Agents
      1. Preferred: Trimethoprim-Sulfamethoxazole (Septra)
      2. Dose: 5 mg/kg/day of TMP component divided bid
        1. Lower dose than usual 8 mg/kg/day
        2. Frequency: Twice daily for 3 days per week
      3. Alternative agents
        1. Dapsone
        2. Atovaquone
    2. CD4 Count to Start Prophylaxis dependent on age
      1. Age under 12 months: All infants on prophylaxis
        1. Start prophylaxis at 6 weeks of age
        2. May stop if HIV PCR still negative at 4 months
        3. Continue until 12 months if HIV positive
        4. Base prophylaxis on CD4 Count after 12 months
      2. Age 1-11 months: CD4 Count < 1500 cells
      3. Age 12-23 months: CD4 Count < 750 cells
      4. Age 2-5 years: CD4 Count < 500 cells
      5. Age >6 years: CD4 Count < 200 cells
  4. Tuberculosis exposure
    1. Testing
      1. PPD skin test (positive if 5 mm or greater)
      2. Chest XRay
    2. Protocol after Tuberculosis exposure
      1. Prophylaxis even if PPD negative
      2. Isoniazid prophylaxis for 3 months
      3. Repeat PPD at 3 months
        1. May stop Isoniazid if PPD negative
        2. Continue Isoniazid if PPD positive
  5. Immunizations
    1. See Immunization in HIV
    2. Influenza Vaccine at 6 months and then yearly
    3. Routine Immunizations
      1. Give IPV instead of OPV
      2. Varicella Vaccine (if CDC Immune Category I)
      3. MMR Vaccine (if CDC Immune Category I or II)

XI. Precautions: Acute Illness

  1. Aggressively manage adolescents with HIV (frequently non-compliant with medication regimens)
  2. Exercise low threshold for admission for children with HIV and a low age-adjusted CD4 Count
  3. Headache and fever should be evaluated with head imaging and Lumbar Puncture
    1. See Headache in HIV

XII. Prevention

  1. Minimize exposure and evaluate infectious contacts
    1. Tuberculosis
    2. Varicella Zoster Virus (VZV)
  2. Prevent opportunistic infection
    1. Avoid undercooked foods (Salmonellosis)
    2. Avoid cat litter box exposure (Toxoplasmosis)
    3. Consider using only bottled or purified water
      1. Giardiasis
      2. Cryptosporidiosis

XIII. Prognosis: Distinct patterns of disease progression

  1. Rapid (30%)
    1. Associated with in utero transmission
    2. Symptom onset in first 6 months of life
  2. Slower (70%)
    1. Symptom onset in first 3 years of life
  3. Adult equivalent (<5%)
    1. Symptom onset at 10 years of life

XIV. References

  1. Church and Claudius in Majoewsky (2013) EM:Rap 13(8): 7-8
  2. (1998) MMWR Morb Mortal Wkly Rep 47(RR-4):1-43 [PubMed]
  3. Krist (2002) Am Fam Physician 65(10):2049-56 [PubMed]

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