Posted by: Indonesian Children | June 14, 2009

HIV IN CHILDREN : FOLLOW UP

Follow-Up

Further Outpatient Care:

  • Children should be monitored every 1-3 months, depending on their clinical status.
  • Anthropometric parameters should be measured and dietary habits reviewed at each clinical visit to monitor growth. A decrease in the growth velocity should alert the clinician to worsening of the underlying disease or inadequate nutrition. Aggressive nutritional management prevents growth failure and improves immune function.
  • Most children with HIV infection have some developmental delay. Developmental assessment and therapy, including physical, occupational, and speech therapies, should be available.
  • Social support staff should continually reevaluate the support system of the child. Children with HIV infection have multiple issues and need extra support from inside and outside the family. Every attempt should be made to support the efforts of a caring family and child.
  • Laboratory values should be monitored.
  • Every 3 months – CD4 count, viral load, CBC
  • Every 3-6 months – Liver function, amylase, lipase, LDH levels
  • Every 6 months – Quantitative immunoglobulin tests, urinalysis
  • Every year – Chest radiography, CMV and Toxoplasma serologic tests if baseline values are negative

Deterrence/Prevention:

  • Compliance with prescribed medications is multifactorial and a major issue in some populations.
  • Children, in general, do not like to take medications, especially if they taste bad. Several medications have an unpleasant taste. Adverse effects, such as gastrointestinal upset, diarrhea, and allergy, may cause the caretaker to discontinue a medication without informing the physician. The vast number of medications can cause compliance problems, even in the most reliable individuals. 
  • The caretaker or child should bring the medications to each clinic visit. The bottles should be checked against a list of prescribed medications kept in the chart. The caretaker or patient should be questioned regarding the particular time and method of administration and should be asked the names of the medications without referring to the bottles. Although some caretakers cannot perfectly complete this task, they may be giving the medications correctly. This method allows the physician to judge the familiarity of the caretaker with the medications and to detect any problems with medication administration. 
  • Known adverse effects of medications should be directly addressed. Some caretakers or patients are scared or embarrassed to disclose adverse effects that may be preventing them from properly using the medications. For example, although a patient may be taking a medication regularly, the medication may induce frequent vomiting, which affects medication delivery. Adolescent patients may avoid taking the medications at school to prevent his or her peers from knowing about the disease. 
  • Partial compliance can be worse than no compliance because resistance occurs when medications are given at subtherapeutic doses. Drug resistance develops rapidly. If the patient is not taking the medication, the virus does develop resistance to the medication, and the medication is still useful for future treatment of the virus. 
  • Administering medications with chocolate or peanut butter can help. Some medications can also be mixed in chocolate milk or pudding. If such a technique is used, proper dental hygiene is important to wash out the sugar after medication administration. 
  • Placement of gastrostomy tube for medication administration is a feasible option in children who cannot be compliant. Such a device also is useful for nutritional supplementation. This option must be planned in advance because the condition of children with advanced HIV can be tenuous, making surgical procedures risky.
  • The risk of vertical transmission may be reduced.
  • Most children are infected by means of vertical transmission. 
  • Proper treatment of the mother during pregnancy and delivery and proper treatment of the neonate can reduce the risk of vertical transmission. Pre-, peri-, and postnatal treatment along with elective cesarean delivery lower the transmission rate to as low as 2%. 
  • Risk factors for vertical transmission are divided into the 4 categories, as shown in Table 1 below.Table 1. Risk Factors for Vertical Transmission

     

    Period Factors That Increase Risk Factors That Decrease Risk
    Prenatal Acute HIV infection
    Viral load >10,000
    Cigarette smoking
    Illicit injection drug use
    Viral load <1,000
    Zidovudine treatment
    Neutralizing antibodies
    Perinatal 4 h
    Chorioamnionitis
    Emergency cesarean section
    Surgical delivery
    Episiotomy
    Scalp electrodes
    Elective cesarean delivery with zidovudine treatment
    Neonatal Prematurity
    Low birth weight
    First-born twins
    Full term-term
    Second-born twin
    Postdelivery Breastfeeding None

     

  • Transmission can occur during 3 periods: prenatal or in utero, perinatal and delivery, and postnatal. 
    • Prenatal transmission appears to occur in 15-38% of vertically acquired HIV infections. 
    • Most vertical infections occur during delivery. 
    • Although the concentration of HIV in the cervicovaginal secretions is lower in women with lower viral loads, HIV particles exist in the cervicovaginal secretions of women with undetectable viral loads. 
    • Any factor that reduces contact between the neonate and maternal blood or cervicovaginal secretions reduces vertical transmission. This observation is supported by the decreased transmission rates with elective cesarean delivery. However, this protective effect occurs only when women were treated with zidovudine during pregnancy. Because the postpartum complication rate is higher for elective cesarean delivery, whether regimens that use highly active antiretroviral therapy can substantially reduce vertical transmission during vaginal delivery, thereby improving both child and mother morbidity and mortality rates, remains to be determined. 
    • Postnatal vertical transmission occurs with breastfeeding and has a transmission incidence of 0.7% per month. 
    • Although recommendations state that women infected with HIV should not breastfeed, the World Health Organization advises women in developing countries to breastfeed because death rates from infectious diarrhea and dehydration are higher than death rates from AIDS.

     

  • The CDC has approved the following regimen to reduce vertical HIV transmission: 
    • Antepartum women – Zidovudine 300 mg by mouth twice a day (In women who present during the prenatal period, zidovudine treatment should be started regardless of the use of other antiretroviral agents and the history of zidovudine resistance.) 
    • Intrapartum women – Continuous IV zidovudine at a rate of 1 mg/kg/h (In women who present in labor, the intrapartum regimen should be started.) 
    • Neonates – Zidovudine within their first 6-12 hours of life until aged 6 weeks (see Treatment)
  • Opportunist infections must be prevented by using primary or secondary prophylactic antibiotics and by avoiding the environmental source of the pathogen.
  • Environmental exposure to pathogens may enhance transmission and infection. Selected opportunistic pathogens and common sources are listed below. 
    • CMV infection – CMV-positive blood products 
    • Cryptosporidium infection – Unprocessed ground water, young or stray animal 
    • PCP- Others with PCP pneumonia 
    • Toxoplasma gondii infection – Cats, undercooked red meat 
    • TB – Exposure to high-risk individuals

     

  • Antibiotics for primary and secondary opportunist infection prophylaxis and the appropriate doses are listed in Tables 2-3. 
    • Prophylactic antibiotic treatment does not guarantee protection, and opportunist organisms should be appropriately included in the workup differential diagnosis of any HIV-infected patient. 
    • Several of the antibiotics used for prophylaxis have significant adverse interactions with antiretroviral agents. For example, rifampin and rifabutin reduce the effectiveness and increase the toxicity of protease and NNRTIs. Also, isoniazid is hepatotoxic and may interact poorly with protease inhibitors that are hepatotoxic. 
    • For further information concerning each opportunistic infection, see Complications.

    Table 2. Antibiotics for Primary and Secondary Opportunistic Infection Prophylaxis

     

     

    Infection and Indication First-Line Regimen Alternative Regimen
    TB
      PPD >5 mm
      Exposure
    Isoniazid and pyridoxine qd x 9 mo
    Isoniazid and pyridoxine 3 times/wk x 9 mo, rifampin and pyrazinamide qd x 2 mo
    Rifampin x 4 mo
    Consult ID if pathogen is multidrug resistant
    PCP
      CD4 finding*
      FUO x 2 wk, H/O infection
      Oropharyngeal candidiasis
    TMP-SMZ qd
    Dapsone, pyrimethamine, and leucovorin
    Atovaquone
    TMP-SMZ 3 times/wk
    Dapsone or aerosolized pentamidine in children >5 y
    None
    Toxoplasmosis
      CD4 count <100 x 109/L
      Positive IgG finding
      Previous infection
    TMP-SMZ qd
    None
    Sulfadiazine, pyrimethamine, and leucovorin
    Dapsone, pyrimethamine, and leucovorin
    Atovaquone
    Clindamycin, pyrimethamine, and leucovorin
    MAC infection
      CD4 finding*
      Previous infection
    Azithromycin qwk
    Clarithromycin or azithromycin qd and ethambutol
    Rifabutin qd or clarithromycin bid
    Clarithromycin or azithromycin qd and ethambutol

    Note: PPD indicates purified protein derivative.
      *See Table 4 below.

    Table 3. Drugs and Doses in Opportunistic Infection Prophylaxis

     

     

     

    Drug Dose
    Azithromycin 20 mg/kg/dose (1.2 g maximum) PO qwk or
    5 mg/kg/dose (250 mg maximum) PO qd
    Clarithromycin 7.5 mg/kg/dose (500 mg maximum) PO bid
    Clindamycin 20-30 mg/kg/d PO qid
    Dapsone 1-2 mg/kg/d (100 mg maximum) PO qd
    Ethambutol 15 mg/kg/dose (900 mg maximum) PO qd
    Isoniazid 10-15 mg/kg/dose (300 mg maximum) PO/IM qd
    Leucovorin 5 mg PO 3 times/wk
    Pentamidine 4 mg/kg/dose monthly
    Pyrimethamine 15 mg/m2/dose (25 mg maximum) PO qd
    Rifabutin 5 mg/kg/dose (300 mg maximum) PO qd
    Rifampin 10-20 mg/kg (600 mg maximum) PO/IV qd
    Sulfadiazine 85-120 mg/kg/d PO bid
    TMP-SMZ 150/750 mg/m2/d PO bid
  • Immunizations for most childhood diseases and other preventable pathogens should be given to the child with HIV infection. 
    • All typical childhood vaccines should be given, with the exception of live vaccines in selected children. 
    • The measles, mumps, and rubella (MMR) vaccine should be given to all children whose disease is not in CDC immune category 3. The second dose should be given as soon as 1 month after the first dose to ensure early seroconversion. 
    • If a recent measles epidemic has occurred, the measles or mono-measles vaccine should be administered as early as possible to all children, except those whose disease is in CDC immune category 3. 
    • Pneumococcal vaccine should be given to children when they are aged 2 years and every 5 years thereafter. 
    • Influenza vaccine should be given yearly to all children older than 6 months and to family members of the patient. 
    • Inactivated poliovirus vaccine should be given instead of the live oral poliovirus vaccine. 
    • Varicella vaccine should be administered to all children whose disease is in CDC category N or A and immune category 1 with a CD4 percentage of more than 25%. Two doses should be given 3 months apart. Otherwise, varicella vaccination is strictly forbidden, and exposure to varicella should be treated with intramuscular varicella-zoster immunoglobulin within 72 hours of exposure.
  • All children should be screened for certain opportunistic infections. 
    • The patient and all family members should undergo yearly TB screening. Candidal or mumps control should be ensured. Allergy to the control indicates yearly chest radiography instead of the use of a purified protein derivative (PPD). 
    • CMV infection accelerates HIV progression in infants. Positive CMV urine culture findings at birth can help guide later management. Cultures not obtained immediately after birth may imply colonization and not congenital infection. CMV infection should not be treated unless it is symptomatic. 
    • Toxoplasmosis, other infections, rubella, CMV, and herpes simplex virus (HSV) (TORCH) infections are not common during gestation in women with well-controlled HIV infection. Women with poorly controlled HIV infection or neonates who have growth retardation at birth, however, should be screened for TORCH infections. Not uncommonly, AIDS patients are toxoplasmosis carriers, and the infection may be transmitted in utero if the mother is severely immunosuppressed during pregnancy.
  • Immunologic function should be assessed in high-risk patients. 
    • Immunoglobulin levels should be checked every 3-6 months. Hypogammaglobulinemia is defined as an immunoglobulin G (IgG) level less than 2.5 g/L. 
    • Humoral immune function can be checked by measuring specific antibody titers after immunization. 
    • Cellular immune function is checked by using a subcutaneous candidal control. 
    • Children with hypogammaglobulinemia, humoral immune dysfunction, or more than 2 serious bacterial infections in a year should receive 400 mg/kg of IVIG every 4 weeks.

 

resource : emedicine

 

Supported by

FIGHT AGAINST  AIDS, SAVE  INDONESIAN CHILDREN

YUDHASMARA FOUNDATION

JL TAMAN BENDUNGAN ASAHAN 5 JAKARTA PUSAT, JAKARTA INDONESIA 10210

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Email : judarwanto@gmail.com 

https://childrenhivaids.wordpress.com/ 

 

Editor in Chief :

DR WIDODO JUDARWANTO

email : judarwanto@gmail.com,

 

Copyright © 2009,  FIGHT AGAINST  AIDS, SAVE  INDONESIAN CHILDREN  Information Education Network. All rights reserved.


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