NURSEREVIEW.

ORG

THE INFANT OF AN HIV-POSITIVE MOTHER

Frequently, the newborn who is subsequently determined to be HIV-positive will be
asymptomatic during the nursery stay. The CDC classifies HIV-positive newborns as
indeterminate, asymptomatic, or symptomatic. Between 20% and 65% of infants born to HIV-
positive mothers are themselves infected.
This plan of care is to be used in conjunction with the previous newborn plans of care.

NEONATAL ASSESSMENT DATA BASE

As a rule, the neonate is asymptomatic at birth, although a few may show signs of
opportunistic infections within several days of birth. In addition, the effects of maternal
substance use/abuse and/or prematurity may be present.

Circulation
Prolonged bleeding, petechiae (thrombocytopenia) noted on occasion

Elimination
Diarrhea
Enlarged liver, spleen may be noted

Food/Fluid
LBW
Feeding difficulties
Oral lesions (candidiasis)

Neurosensory
Neurological deficits
Microcephaly

Respiration
Varied degree of impairment (relative maternal drug use, cesarean birth)

Safety
Swollen glands (lymphadenopathy) noted on occasion
MATERNAL FACTORS
History of high-risk behaviors, STDs
Seropositive HIV

Sexuality
MATERNAL FACTORS
History of multiple sexual partners

Teaching/learning
Prematurity
Developmental delays
 MATERNAL FACTORS
History of parental drug use (mother or partner)

DIAGNOSTIC STUDIES
CBC and Total Lymphocyte Count: Provides baseline immunologic data regarding WBC and
lymphocyte counts to monitor disease progression.
Enzyme Immunoassay or Enzyme-Linked Immunosorbent Assay and Western Blot
Test (EIA/ELISA): May be positive, but invalid because test does not distinguish between
maternal and infant antibodies. (The infant may test negative by 9–15 mo of age.)
HIV Cultures (with peripheral blood mononuclear cells and, if available, plasma):
Diagnostic for infants under 15 mo of age.
Polymerase Chain Reaction Test: Detects nucleic acid in small quantities of infected
peripheral mononuclear cells.
Serum or Plasma p24 Antigen: Increased quantitative values can be indicative of
progression of infection (may not be detectable during very early stages of HIV infection)
in infants 30 days or older and who have had the second dose of hepatitis vaccine.
Quantitative Serum IgG, IgM, and IgA Determinations: Nondiagnostic in newborns, but
provide baseline immunologic data.
Blood/Lesion/Urine Cultures: Diagnostic for opportunistic infections.
X-ray: May reveal lymphoid interstitial pneumonia.

NURSING PRIORITIES
1. Prevent/minimize infections.
2. Maximize nutritional intake.
3. Promote attachment, growth, and development.
4. Provide information to parent(s)/caregivers about disease process/prognosis and treatment
needs.

DISCHARGE GOALS
1. Free of opportunistic/nosocomial infection.
2. Gaining weight appropriately.
3. Perform skills typical of age group within scope of present developmental level.
4. Parent/caregiver understands condition/prognosis and treatment needs.
5. Plan in place to meet specialized needs after discharge.

NURSING DIAGNOSIS: INFECTION, risk for

Risk Factors May Include: Immature immune system, inadequate acquired
immunity, suppressed inflammatory response, invasive
procedures, malnutrition, chronic disease (infections)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of opportunistic infection.
CRITERIA—NEONATE WILL:
PARENT/CAREGIVER WILL: Verbalize understanding of individual risk factors.
Identify interventions to reduce risk of infection.
Provide safe environment for infant.
ACTIONS/INTERVENTIONS
Independent
Note maternal HIV status/presence of high-risk
behaviors, and prenatal/intrapartal use of
zidovudine (AZT).
Use mechanical suction or bulb syringe in place of
oral mucus extractors (e.g., DeLee trap) to clear
airways. Avoid mouth-to-mouth contact for
resuscitation.
Wash neonate at time of delivery, or as soon as
possible, using warm water and mild soap.
Minimize exposure to maternal blood and
body fluids.
Provide customary physical care of neonate (e.g.,
skin care, eye care, vitamin K administration) the
same as for all newborns, using universal
precautions.
Stress need for care providers/family members
washing hands before and after contact with infant.
Wear gloves for contact with secretions (e.g.,
diapering, cord care, injections, handling of blood/
blood by-products).
Sealed soiled tissues, paper wipes/trash, and
disposable diapers in plastic bags per protocol.
Apply mittens; file infant’s nails, as indicated.
Monitor temperature and secretions. Auscultate
breath sounds. Note behavioral changes, e.g.,
irritability, lethargy. Palpate lymph node chains.
Prepare skin with soap and water and then alcohol
prior to injections/heel-sticks. Notify laboratory of
HIV status and mark specimens accordingly.
Monitor/limit contact with care providers and
family members, as appropriate.
Provide for complete isolation as indicated.
RATIONALE
Affects care of neonate from time of delivery. Anti-
HIV antibodies are transmitted across the placenta
and are present in all infants of HIV-seropositive
mothers. Between 20% and 67% of these infants will
themselves eventually test positive for HIV. Note:
Maternal antibodies may not be cleared from infant’s
system until 9–15 mo of age.
Prevents exposure of healthcare provider to virus.
Although maternal blood is contaminated, at birth
infant may not be HIV-positive. Prompt care may
help reduce risk to infant.
Universal precautions are routinely required for
contact with body fluids/blood products to protect
the healthcare provider from potential infection.
Reduces risk of cross-contamination and risk to
care providers.
Reduces risk of cross-contamination and alerts
appropriate personnel/departments to exercise
specific hazardous materials procedures.
Protects skin from injury that can provide additional
portals of entry for infectious agents.
HIV-seropositive infants have increased risk for
developing recurrent upper respiratory infection,
otitis media, thrush, cytomegalovirus, erythematous
rash, and lymphadenopathy. Note: Although
Pneumocystis carinii pneumonia (PCP) is common is
both infants and adults, lymphocytic interstitial
pneumonitis (LIP) is rarely seen in adults and is the
second most common indicator disease for
diagnosing AIDS in infants.
Proper preparation and handling reduces risk of
cross-contamination for infant and care
providers/laboratory staff.
Reduces number of pathogens presented to the
infant’s immune system and decreases possibility of
infant’s contracting a nosocomial infection. Note:
Depending on specific facility policy, pregnant care
providers may be excluded from caring for infant to
reduce risk of HIV contamination.
Presence of enteritis, congenital syphilis, CMV, or
other viral infections increases risk of cross-
contamination to other infants.
Investigate sudden fever, dyspnea, dry cough,
hypoxia, abnormal breath sounds, or use of
accessory muscles, retractions and nasal flaring.
Observe infant for seizure activity, neck stiffness,
muscle rigidity, irritability or lethargy, or positive
Kernig’s sign.
Collaborative
Monitor laboratory studies as indicated:
Urine screening;
IgG, IgM, IgA;
CD4 counts;
CBCD, liver function tests.
Administer medications, as appropriate:
Zidovudine (AZT/ZVD);
cidobudine (CBD); trimethoprin (TMP);
sulfamethasoxazol (SMX) 2 divided doses;
didanosine (Videx);
ketoconazole (Nizoral);
trimethoprim-sulfamethoxazole (Bactrim)
prophylaxis;
Triple dye, bacitracin;
Ganciclovir (Cytovene).
Recommend/coordinate periodic ophthalmologic
examinations as appropriate.
Up to 50% of HIV-infected infants develop PCP
during 1st yr of life.
Suggests meningitis or opportunistic CNS
infection. Note: If symptoms develop slowly over
weeks, may reflect HIV effect on CNS rather than
acute infectious process.
Increased risk of CMV in utero or during hospital
stay necessitates routine microscopic evaluation.
Note: Once infant is discharged, exposure to CMV is
a risk in day-care setting as well.
Elevated serum immunoglobulins are a hallmark of
pediatric HIV infections and may develop before the
decrease in CD4 (T-helper cells) is noted. Note:
Polyclonal hypergammaglobulinemia occurs in
approximately 80% of infected infants, usually in
first months of life.
Decline reflects immunologic compromise and need
for institution of AZT therapy. Note: CD4 counts of
3000/m3 or more are normal in healthy infants and
gradually decline to adult levels. Counts below
1500/mm3 in 1st yr place infant at increased risk of
developing PCP.
Establishes baseline prior to initiation of drug
therapy to be compared with repeat studies at 2, 6,
and 12 wk of age to monitor effects of
therapy/progressions of condition.
Useful in preventing replication of HIV in infants older
than 3 mo of age; however, side effects may limit its
usefulness. Note:Recent CDCpublications recommend
6 wk of combination therapy beginning within 12 hr of
birth for infants born to seropositive mothers.
Given orally immediately following birth to prevent
Pneumocystis carinii pneumonia
May be used to treat HIV strains resistant to AZT.
Effective treatment for systemic yeast infections.
Instituted for symptomatic infants or
asymptomatic infants with CD4 counts below
500/mm3 to prevent PCP.
Antimicrobial agents used in cord care to reduce risk
of infection.
Treatment of choice for CMV infection to prevent
blindness/life-threatening dissemination.
Early detection of retinitis in presence of CMV
infection allows for prompt intervention.
 NURSING DIAGNOSIS:
Risk Factors May Include:
Possibly Evidenced By:
DESIRED OUTCOMES/EVALUATION
CRITERIA—NEONATE WILL:
PARENT/CAREGIVER WILL:
ACTIONS/INTERVENTIONS
Independent
Obtain baseline weight. Establish regular
schedule for weighing following discharge
(e.g., three times per week). Identify resources if
scale is not available in home setting.
Observe coordination of sucking and
swallowing reflexes.
Inspect oral cavity. Review procedure with
caregivers.
Counsel mother regarding risk of breastfeeding.
Encourage alternative feeding method.
Note infant tolerance of feedings.
Hold infant during feedings.
Observe feeding techniques of caregivers. Provide
assistance and encouragement.
NUTRITION: altered, risk for less than body
requirements
Inability to ingest, digest, or absorb nutrients (e.g.,
impaired suck/swallow, GI infection, malabsorption,
diarrhea)
[Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
Demonstrate progressive weight gain toward
goal.
Display laboratory values WNL.
Be free of signs of malnutrition/FTT.
Demonstrate understanding of feeding techniques and
infant’s specific needs.
RATIONALE
These infants are at increased risk for FTT as
evidenced by weight loss or little weight gain
from birth. Early recognition provides opportunity
for prompt intervention. Note: If infant is eating
well, but not gaining weight, evaluate for GI
infection.
Abnormal oral motor patterns may impair feeding
ability.
Development of oral sores (e.g., thrush) impairs
ability to feed, and, if untreated, can spread to the
esophagus, necessitating alternative feeding
techniques.
HIV is present in colostrum and breast milk and
although limited, does present some risk to the
infant.
Feeding difficulties, gastric distress, or signs of
fatigue may require small, frequent feedings for
optimal intake.
Provides human contact/stimulation and may
enhance intake.
Attention to positioning and handling may be
required to normalize postural tone while feeding
and to maximize sucking/swallowing efforts.
Investigate presence of diarrhea. May indicate lactose intolerance requiring lactose-
free formula or reflect GI manifestations of HIV
infection (e.g., diarrhea, malabsorption, impaired
gastric motility, and liver dysfunction).

Stress importance of close monitoring for
infectious processes.
Infant is prone to parotitis, as well as frequent
episodes of rapid-onset pneumonia, interfering with
both appetite and feeding. In addition, presence of
infectious process greatly increases metabolic rate
and thereby nutritional needs.

Review future nutritional needs, age-appropriate Provides optimal nutrition based on individual
diet and addition of solid foods considering needs following discharge.
developmental abilities.

Collaborative
Provide enteral/parenteral feedings as appropriate.
Obtain stool specimens, as indicated.
Administer nystatin, as indicated.
Motor impairments and/or presence of infection
may necessitate alternative feeding techniques
to meet dietary needs/prevent dehydration.
Stool cultures; tests for ova/parasites,
Cryptosporidium, C. difficile (toxin produced by
bacteria), acid-fast bacillus and Gram’s stain may
identify causes for gastric distress/diarrhea
and weight loss or failure to gain.
Effective treatment for oral yeast infection.

NURSING DIAGNOSIS: GROWTH AND DEVELOPMENT, risk for altered

Risk Factors May Include: Separation from significant others, inadequate
caretaking, inconsistent responsiveness/multiple
caretakers, environmental and stimulation deficiencies,
effects of chronic condition/disabilities
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Respond to parent/caregiver interactions.
CRITERIA—NEONATE WILL: Perform motor, social, and/or expressive skills typical of
age group, within scope of present capabilities.
PARENT/CAREGIVER WILL: Verbalize understanding of developmental status and
plans for intervention.
Demonstrate skills in handling infant needs.

ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine individual status using Denver
Developmental or similar screening tool.
Identify developmental milestones and
anticipated time frames for achievement.
Discuss caregiver’s perceptions of infant’s
capabilities and plan for growth.
Observe infant-parent/caregiver interactions.
Encourage verbalization of feelings by
parent(s)/family members.
Avoid confronting denial. Counsel without
lecturing, provide information without
patronizing, and support and give hope
without making false promises.
Encourage/support family efforts to care for infant.
Discuss ways to provide a normal atmosphere
(e.g., spending time outdoors, using support
systems effectively).
Collaborative
Coordinate multidisciplinary team conference to
include pediatrician, primary nurse, social worker,
nutritional support, psychologist/psychiatrist or
clinical specialist psychiatric nurse, physical/
occupational therapists, and speech therapists.
Provides baseline to note future progress/changes
and identify therapy needs. Cognitive impairments
vary, may be present at birth, or may develop as a
result of environmental deprivation or viral
infections affecting the CNS. In addition, some
infants may have delayed sensorimotor
development, while others display abnormal muscle
tone and movement patterns with delayed
development of righting and equilibrium reactions.
(Refer to CP: Deviations in Growth Patterns.)
Reinforces belief that infant may progress with
appropriate support and interventions. Note: Lack of
development or regression is an indicator of need for
further evaluation and may reflect effect of infectious
process.
Increased frequency of illness, prolonged/recurrent
hospitalizations, neglect/overprotection by
caregivers may limit sensory/movement stimuli and
motivation.
Eye contact, reaching out of infant promotes adult
response. Effect of maternal drug use, presence of
illness, or developmental delays may prevent or limit
infant interactions, impairing bonding/attachments.
Frequently, feelings of guilt and despair may be
expressed as hostility, denial, or defensiveness
regarding diagnosis. Awareness of these feelings
provides opportunity to work through them and
develop a positive relationship with the infant.
Parent(s) need to progress at their own rate and
denial may be very strong especially when the
infant is asymptomatic. Providing information,
Active-listening, and acceptance of the person in
nonjudgmental ways promotes more positive
progression to acceptance and resolution of dealing
with reality of the situation.
Personal interactions, even after a period of
abandonment, enhance the bonding process. Note:
Volunteers may be required to support staff efforts in
the absence of family participation or ineffective
family involvement.
Enhances sense of control and provides
encouragement for enjoying the present and
possibilities of the future.
Necessary to address complex issues and
maximize infant’s potential because all areas are
interrelated to growth and development.
Stress importance of frequent screening and formal
evaluations by developmental specialists.
NURSING DIAGNOSIS:
May Be Related To:
Possibly Evidenced By:
DESIRED OUTCOMES/EVALUATION
CRITERIA—PARENT/CAREGIVER WILL:
ACTIONS/INTERVENTIONS
Independent
Determine parent(s)’/caregivers’ understanding
of condition and prognosis.
Provide realistic, optimistic information during
each contact with parent.
Note response to contact with infant by parent(s)/
family, and other caregivers. Discuss individual
concerns.
Identifies developmental delays and effectiveness
of therapy (e.g., early intervention program [EIP]).
KNOWLEDGE deficit [Learning Need], regarding
condition, prognosis, and treatment needs
Lack of exposure, misinterpretation, unfamiliarity with
resources, lack of recall, lack of interest in learning
Request for information, statement of misconceptions,
inaccurate follow-through of instructions, development
of preventable complications
Verbalize understanding of condition and
treatment needs.
Identify signs/symptoms requiring intervention.
Perform necessary procedures correctly and explain
reasons for the actions.
Establish plan for ongoing therapy and evaluations.
RATIONALE
Provides starting point for information and
opportunity to clarify misconceptions. Incubation
period of initial HIV infection to progressive
encephalopathy varies from 2 mo to 5 yr. HIV
directly affects CNS, cardiovascular, GI, and renal
function. Median age for appearance of opportunistic
infection is 9 mo. Impaired brain growth, loss of
developmental milestones, and progressive motor
dysfunction indicate a very poor prognosis. Note:
Children rarely develop Kaposi’s sarcoma,
tuberculosis, toxoplasmosis, cryptococcosis, or
histoplasmosis.
Enhances attachment process and reduces
likelihood of abandonment. Many people have been
exposed to media information about AIDS or have
friends/lovers who have died of the disease, and
parent/caregiver may be pessimistic about outcome
for infant.
Interactions may be affected by fear of
contamination and of personal judgments
regarding suspected high-risk behaviors of parents.
Note: To date, there have been no documented cases
of individuals contracting AIDS from routine care of
infected infants when following established CDC
precautions.
Note roles of family members and availability of
extended family.
Review current medication/treatment options.
Discuss safe formula preparation and
feeding techniques.
Recommend prompt diaper changing/perineal
care, use of disposable gloves, and proper
handling of soiled diapers/other pericare items.
Identify ways to protect infant from exposure to
common infections, diseases, or contact with
recently vaccinated individuals.
Stress importance of routine immunization
as appropriate.
Review side effects of therapy, e.g., AZT.
Determine current living conditions, physical
care needs, immune status/presence of
opportunistic infections.
Discuss placement options as appropriate.
HIV infection is frequently a multigenerational
disease, directly affecting mothers, offspring, and
other family members. Because the mother must deal
with her own chronic illness, awareness of the role of
the father and/or grandparents is necessary in
determining family needs or necessity of alternative
placement.
Research is ongoing and often openly discussed in
the media, sometimes raising false hopes that must
be clarified to enhance the decision-making process.
Current studies suggest monthly IV immunoglobulins
(IV-Ig) may reduce infections and incidence of
hospitalization. In addition, trials of experimental
vaccines for asymptomatic HIV-seropositive infants
are presently being tried in the hope of enhancing the
response of the immune system.
Reduces risk of bacterial infection and aspiration.
Note: Infant should not be put to bed with
formula/juice bottle because of risk of bacterial
growth.
Reduces risk of skin irritation providing entry of
infectious agents. Protects others from exposure to
HIV.
Impairment of immune system reduces infant’s
ability to ward off disease. Depending on infant’s
immune status, placement in day care may be
contraindicated to reduce risk of cross-contamination
from other infants.
Provides protection from some infectious agents.
Note: Infant should receive injectable (Salk) instead
of oral (Sabin) polio vaccine, which contains live
virus. In addition, asymptomatic infants do not
require influenza vaccine.
Nausea/vomiting, abnormalities of liver function,
and suppression of bone marrow limit therapy/drug
dosage.
Mother’s lifestyle/condition may preclude her
providing appropriate care for infant. Other family
members (e.g., grandparents, aunt/uncle) may be
providing care for mother and/or other involved
family members and be unable to care for infant too.
Chronically ill/impaired mother and extended
family members who may be overtaxed with caring
for ill family members may not be able to meet the
needs of even a well infant. Residential or foster
home may be indicated at least for a period of time
until family or parent(s) are able to assume
responsibility for infant. However, many foster
homes refuse HIV-infected infants, and as a rule,
these children are not usually available for adoption,
making placement very difficult.
Stress frequency and content of follow-up care,
especially with health professionals experienced
in caring for HIV-seropositive women and infants.
Discuss significance of HIV and other testing.
Identify signs/symptoms requiring notification of
healthcare provider, e.g., fever, pain, altered
activity level, difficulty breathing, poor appetite,
weight loss, vomiting, diarrhea, skin rashes,
oral thrush, or developmental regression.
Encourage parents/caregivers to care for their own
health and to make time to meet their own needs
for rest and relaxation.
Review individual/family coping strategies.
Discuss/encourage use of effective stress
management techniques, including use of
medication/prayer as appropriate.
Identify sources for family counseling, community
support groups, and other resources (e.g., visiting
nurse services, home care agency, social services,
respite care).
Knowledgeable providers are better equipped to
deal with the complex health issues and use newly
developed treatment options to promote optimal
outcomes for the infant/family.
Regular testing to age 2 is necessary to verify HIV
status in absence of opportunistic infections. Viral
cultures, polymerase chain reaction, IgA, IgM, p24
antigen assay, and evaluation of CD4 lymphocyte
count monitor presence/progression of infection. In
addition, some resources believe all infants born to
HIV-risk women require vigilant pediatric follow-up
for early diagnosis of true HIV infection.
Prompt evaluation and intervention may limit
process and progression to AIDS.
As they learn to take time for themselves,
parents/caregivers can better manage long-term
care of a chronically ill child.
Individuals providing care for infant with complex
medical regimen and emotional needs are exposed
to multiple, continuous stressors that can
quickly exhaust coping abilities, increasing risk for
caregiver role strain.
Mother-infant dyads are at increased risk for
impaired bonding. Physical illness, financial
stressors, depression, maternal drug use, and
poor support systems interfere with parenting
abilities, placing infant at risk for physical and
emotional neglect/abuse. In addition, family
members will require assistance in coping with
chronic illness and future prognosis of other family
members. Note: Recent studies suggest mothers who
provide primary care for their infant with HIV report
lower quality of life scores as compared to alternative
caregivers, reflecting need for special
attention/support of this population.