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Short Notes d) PEDIATRIC HIV: Human immunodeficiency virus: It is the member of the Retroviridae family and belongs to the

Lentivirus genus that infects mainly helper T lymphocytes (CD4 lymphocytes), monocytes and macrophages AIDS is the immunologic deficiency disorder which is caused by HIV which destroys the bodys ability to fight infection. OR It is the result of progression of HIV infection. EPIDEMIOLOGY: The World Health Organization (WHO) estimated that more than 38.6 million persons worldwide were living with HIV infection at the end of 2007; 2.3 million of these were children under 15 years of age. Approximately 90% of pediatric HIV infections are acquired from infected mother. Mother to child transmission may occur passively in uetro (30-35%) during delivery (60-65%) and also through breast feeding ( 10-15%). AIDS ranks among the top ten causes of the death in children aged 1-4 years. ETIOLOGY: There are two types of transmission:

Horizontal Vertical Transmission Transmission HORIZONTAL TRANSMISSION Horizontal transmission of HIV occurs through intimate sexual contacts or parental exposures to blood or body fluids containing visible blood. Infection is transmitted to children through transmission of infected blood before mandatory screening of blood and blood products. Most of these children are infected during treatment f hemophilia. VERTICAL TRANSMISSION

This is also called peri-natal transmission occurs when an HIV infected pregnant woman passes the infection to her infant. Transmission can occur during the birth from blood, amniotic fluid and exposure to genital tract secretions, and after birth through breast milk from HIV positive mother. PATHOPHYSIOLOGY: Any cause either vertical or horizontal

Human immunodeficiency virus enters the blood of infant or children

HIV destroys the helper T cells (target cells)

Virus sheds protein coat

Viral RNA is converted with reverse transcriptase into viral DNA

Viral DNA integrates with host cell DNA

Virus infects daughter cells and results in the lysis of the infected cell

The net result of an HIV infection is decreased cellular immunity CLINICAL MANIFESTION The neonate is asymptomatic at birth. The time period for development of opportunistic infection varies; however, the interval from HIV infection to the onset of overt AIDS is shorter in children than adults, and shorter in children infected perinatally than in those infected through transfusion. When infected, the child with HIV is classified as: 1. Category N: not symptomatic 2. Category A: mildly symptomatic with two or more of the following: Lymphadenopathy Hepatomegaly

Splenomegaly Dermatitis Parotitis Recurrent or persistent upper respiratory infection 3. Category B: moderately symptomatic with additional previous symptoms: Anemia Cardiomyopathy Hepatitis Nephropathy Diarrhea Toxoplasmosis 4. Category C: severely symptomatic: Multiple, recurrent infection Encephalopathy Lymphoma Wasting syndrome

DIAGNOSTIC EVALUATION: Most children with AIDS are diagnosed early in life. 1. Serologic test for the detection of virus performed within 48 hours of birth, are monitored in infants born to HIV positive mothers. 2. Infants with initially negative test should be retested at 1-2 months. 3. Tests are again repeated at 3 and 6 months, and then again at 15 and 18 months. 4. The most preferable test is polymerase chain reaction (PCR) and other test include p24 antigen, or HIV culture (which is not universally available). 5. When the infant has had two negative tests, testing with enzyme-linked immunosorbent assay (ELISA; HIV antibody) should be done at 12, 15 and 18 months. 6. After two consecutive negative results with ELISA, the child is considered free of HIV. 7. In addition, complete blood count and CD41 T-cells subset is performed at 3-6 months. 8. The Centers for Disease Control and Prevention (CDC) considers childhood under 13 years of age to be infected if their symptoms meet the CDC criteria for AIDS. 9. Laboratory tests are used to determine the severity of disease which includes VIRAL the number of circulating HIV particles per millimeter. Viral loads of less than 10,000 are low risk. Viral loads of 10,000-100,000 are moderate risk. Viral loads greater than 100,000 are high risk.

A T4 (CD4) count of >500 cells/mm3 for 6-12 years of age, 71000 cells/mm3 for 1-5 years of age, and 71,500 cells/mm3 for 12 months of age represents a component immune system.

Management of infant and children with AIDS: It includes medical management and nursing management. Medical management: Medical management begins with prevention of the HIV from mothers to newborn. Due to the rapidity of the disease progression in perinatally transmitted HIV infection, early identification of infected infants is important to ensure the most effective treatment. Pregnant women with HIV infection who are treated with zidovudine (AZT) and deliver their babies by cesarean section reduce the chance of transmission to 1%. All infected mother should receive oral zidovudine (AZT) after the first trimester of pregnancy and intravenous AZT during labor and delivery; in addition, the newborn of an infected mother should receive 6 weeks of oral AZT after birth. All infants of infected mothers should start prophylaxis against PCP, a pneumocystis carinii pneumonia ( a commonly serious or fatal outcome in infants) by the age 4-6 weeks of age and continue to 12 months. Drugs used for PCP prophylaxis include Trimethoprim-sulfamethoxazole. Dapsone or aerosolized pentamidine. A CBC with differential is performed at birth, 4-6 weeks, and 12 weeks to monitor for drug side effects

Nursing management: 1. ASSESSMENT: Physiologic assessment: Assessment centers on observation and evaluation of potential sites of infection. Assess the breath sounds, respiratory status, arterial blood gases, level of consciousness, and mental status. Any developmental delays in motor skills or intellectual functioning, which could results from encephalopathy and poor nutrition, and can signal an increasing severity in symptom level. Psychosocial assessment: Assess family support system and coping mechanisms. Assess the familys ability to care for the child. If the mother is infected, inquire about the extended familys ability to provide daily care as well as emotional support. 2. DIAGNOSIS AND INTERVENTIONS:

The accompanying nursing care plan includes common nursing diagnosis that apply to child hospitalized with AIDS. Other nursing diagnosis may include the following: Diagnose 1) organisms. Interventions: a) b) c) d) e) Use hand-washing techniques to minimize exposures to infective organisms. Advice visitors to use good hand washing technique. Place child in room with non infectious children or in private room. Restrict contact with persons who have infection. Administer antibiotics as prescribed. Risk for infection related to impaired body defenses, presence of infective

Diagnose 2. Chronic pain related to disease process (i.e., encephalopathy, treatments) Interventions: a) b) c) d) Assess pain. Observe for sign of pain and discomfort. Medicate for pain as ordered, monitor and document result. Implement general comfort measuring e.g position or holding.

Diagnose 3: Altered nutrition: less than body requirements related to recurrent illness, diarrheal losses, loss of appetite. Interventions: a) Provide high-calorie, high-protein meals and snacks to meet body requirements for metabolisms and growth. b) Provide food child prefers to encourage eating. c) Fortify foods with nutritional supplements to maximize the quality of intake. d) Provide meals when child is most likely to eat well. Diagnose 4: Impaired social interaction related to physical limitations, hospitalizations, social stigma toward HIV infection. Interventions: a) Assist child in identifying personal strength to facilitate coping. b) Educate school personnel and classmates about HIV infection so that child is not unnecessarily isolated. c) Encourage child to participate in activities with other children and family.

Discharge planning: a) The diagnosis of AIDS is surrounded by strong emotions and fears. b) Be honest and direct. c) Explain that there is no evidence that casual contact among family members can spread the infection. d) Discuss the familys finances as well as health insurance coverage for the childs care. Assess the familys ability to provide nutritious food, required medications, and a supportive environment. National AIDS Control Organization Guidelines for HIV care and treatment in infants and children The National AIDS Control Organization would like to acknowledge the support provided by Indian Academy of Paediatrics, Clinton Foundation, UNICEF and the WHO Country Office (India) in the development of these guidelines. Care of exposed child immediately at birth Care of HIV-exposed infants should follow standard neonatal care according to safe motherhood guidelines including the following: 1. The babys mouth and nostrils should be wiped as soon as the head is delivered. 2. Infants should be handled with gloves until all blood and maternal secretions have been washed off (early baby bathing). 3. The cord should be clamped soon after birth. Diagnosis of HIV infection in children < 18 months For children < 18 months old, both breastfed and non-breastfed, born to a HIV positive mother the following testing strategy applies according to the NACO programme: 1. The first HIV DNA PCR shall be conducted at 6 weeks of age. If the PCR test is positive, the test is to be repeated immediately (or as early as possible) for confirmation. 2. If the first PCR is negative in a non-breastfed baby, confirm with a second PCR test at 6months. 3. If the child is breastfed and initial PCR test at 6 weeks is negative, PCR testing should be repeated at 68 weeks after cessation of breastfeeding to rule out HIV infection. 4. In case of mixed -feeding the same strategy to be applied as for a breast fed baby.

5. If symptoms develop at any time, the child should be tested appropriately (PCR orELISA/rapid) at that age. 6. A report of HIV Positive is given when 2 PCR tests are positive; and a r eport of HIV negative is given when 2 PCR tests are negative.

Nutrition in HIV infected infants and children I HIV-infected infants should follow the below protocol: 1. Be measured monthly, using the standardized growth curves. 2. Thereafter, children should be weighed at each review and full nutritional assessments should be made every three months unless the child in question requires particular attention because of growth problems or special nutritional requirements. Palliative care in childrend These guidelines describe that palliative care: 1. 2. 3. 4. 5. 6. Provides relief from pain and other distressing symptoms Affirms life and regards dying as a normal process Intends neither to hasten nor postpone death Integrates the psychological and spiritual aspects of patient care Offers a support system to help the patient live as actively as possible until death Offers a support system to help the family cope during the patients illness and in their own bereavement 7. Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated Will enhance the quality of life, and may also positively influence the course of illness.