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Management of Infants born to HIV Positive Mothers
Joyce BangaNeonatal Nurse
What is the Extent of the problem in Romania?
WHO data regarding HIV/AID infection 2012 revealed
New cases detected =754
Children between 0-14 years =19
Vertical transmission =16
TRANSMISSION PREVENTABLE THROUGH EVIDENCE BASED PRE AND POSTNATAL CARE
Holistic approach to care of the infant
Care starts with multidisciplinary management of the mother in the antenatal period with good communication
Post delivery care of the infant focuses on – 1-Initial blood tests 2-Post exposure prophylaxis 3-Management of risk
factors for infection 4-Feeding
Emotional support of parents/carers
Discharge planning
Follow up appointments and Immunisations
Who are the members of the Antenatal Multidisciplinary Team?
•HIV GUM Consultant
•HIV Lead Consultant Obstetrician
•Specialist Screening Midwife
•Health Advisor
•Community Midwife
•Consultant Neonatologist
What is the Role of the Multidisciplinary Team
Discusses confidentiality and related care issues with the woman
Initial visit, verbal and written information on plan of care
Screening of infections offered
Follow up visits and antenatal scans arranged
Referral to Consultant Neonatologist for a management of plan for the baby post delivery. Concise information on what care to be given and rationale. Well documented.
Woman given chance to ask questions
Monthly Team discusses progress of all cases
Management of the Neonate – Post Exposure Prophylaxis
Wash baby immediately
Weigh baby to allow drug calculation. Zidovudine/HAART following
discussion with Neonatologist (individualised care) – HIGH RISK
Give antiretroviral medication within 4 hours of delivery orally
Educate mother drug administration
If preterm or sick neonate, give intravenous antiretroviral
Evidence of efficacy of PEP – Paediatric AIDS Clinical Trials Group Protocol 076 (ACTG 076) Connor et. al. (1994)
Who is the HIGH RISK BABY?
Mother has had <4 weeks antiretroviral therapy before delivery
Mother has persistently detectable viral load despite ART
The mother is found to be HIV infected after the infant has delivered, and the infant is less than 72 hours of age
The mother has had rupture of membranes >4 hours
Baby’s skin or mucosa have been breached, e.g. scalp electrode or accidental injury during C/S or forceps delivery
Initial blood tests (Day 1)
Obtain consent from parents
Collect blood sample from baby for HIV PCR (not cord blood) – can be contaminated with maternal blood
Maternal sample for HIV PCR – to ensure that the PCR primers used can detect the maternal virus. (different forms)
U&E + LFT to exclude in utero toxicity
FBC to exclude anaemia a side effect of Zidovudine
A viral load from mother
Hepatitis B Vaccination
If the mother is Hepatitis B+ve, give vaccine within the first 24 hours of age.
Ensure the Hep B notification form is completed so that the course is completed in the community.
Explain the importance of completing the course to the parents.
FEEDING
Give facts and advice against breastfeeding
Evidence – Simonon et. al. (1994) Kigali Rwanda.
If preterm give formula milk
If very preterm, consent for donor breast milk
Counsel re-stigma attached to not breastfeeding ( risk vs. stigma)
Postpartum Management of Women who are HIV Positive
An immediate dose of oral Cabergoline to suppress lactation
Encourage bonding with baby – open visiting for parents
Emotional support coming to reality with own infection while facing uncertainty about HIV status of their infant
Family support
Psychosocial meetings – avoid baby abandoning
Discharge Planning
? Need for interpreter service/Follow up clinics discussed
Ensure 4 weeks supply of antiretroviral treatment/formula milk supply
Ensure fixed aboard and confirm address before going home
Give advice on exposure to measles, shingles or chicken pox
Advice on early warning signs of opportunistic infection
NO BCG vaccination to be given prior to the infant’s negative status being confirmed
Include information in the discharge letter to avoid inadvertent BCG immunisation
Subsequent Outpatient Management
6-8 Weeks
Growth and development monitoring
FBC to monitor bone marrow depression
HIV PCR
Hep and Immunisation schedule followed
Week 12
Growth and development monitoring
HIV PCR
FBC
Hep B vaccine and immunisation schedule
If PCR negative – offer BCG immunisation
12 Months
General clinic review
18 Months
General clinic review
HIV antibody and HIV PCR. If negative and infant well, discharge from clinic
On Reflection
Mardarescu et al (2013) in their 12 year survey on 517 children aged 0-18 months confirmed = 15% infected with HIV
Some of the causes for transmission around Neonatal care. Breastfeeding and lack of prophylaxis in children
CONSEQUENCIES1. Psychological implications to the family2. Quality of life3. Costs from Paediatric to adulthood. Postma et al (2000)
estimated Paediatric care to £179 300
Any questions?
References
1. Connor EM, Rhoda MD, Sperling et al . (1994) Reduction of maternal-infant transmission of human immunodeficiency virus Type 1 with Zidovudine treatment. The New England Journal of Medicine 331 (18): 1173-1180.
2. Postma MJ, Beck EJ, Hankins CA et al. (2000) Cost effectiveness of expanded antenatal HIV testing in London. AIDS 14: 2383-2389.
3. Mardarescu M, Petre C, Streinu-Cercel A et al. (2013) Surveillance of mother to child transmission of HIV in Romania, a 12 year’s experience in the National Institute for Infectious Diseases ‘Prof. Dr. Matei Bals’ BMC Infect Dis 13(Suppl1)