1 / 23

CARE OF THE NEONATE

CARE OF THE NEONATE. Infants Born to Mothers with Unknown HIV Infection Status (1). Determine possible HIV exposure and need for infant ARV prophylaxis: Perform rapid HIV test on infant or mother as soon as possible after birth. (AII) If rapid test result is positive:

sydney
Download Presentation

CARE OF THE NEONATE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CARE OF THE NEONATE

  2. Infants Born to Mothers with Unknown HIV Infection Status (1) Determine possible HIV exposure and need for infant ARV prophylaxis: • Perform rapid HIV test on infant or mother as soon as possible after birth. (AII) • If rapid test result is positive: • Immediately initiate infant ARV prophylaxis (AII) • Do not wait for confirmatory testing • Send confirmatory test (mother or infant) • If negative, stop infant ARV prophylaxis (AIII) • If positive, perform an HIV DNA PCR on the infant (AIII) www.aidsetc.org

  3. Infants Born to Mothers with Unknown HIV Infection Status (2) • If infant HIV DNA PCR result is positive: • Discontinue ARV prophylaxis • Promptly refer to an HIV specialist for confirmation of diagnosis and HIV treatment with standard combination ART (AI) www.aidsetc.org

  4. Infant Antiretroviral Prophylaxis (1) • All HIV-exposed infants should receive a 6-week course of ZDV prophylaxis. (AI) • If the mother received standard antepartum and intrapartum ARV prophylaxis with suppressed HIV RNA, risk of HIV transmission is very low; infant ZDV alone is recommended. • If the mother did not receive optimal antepartum and intrapartum prophylaxis, risk of HIV transmission is higher, and additional infant ARVs may be recommended. www.aidsetc.org

  5. Infant Antiretroviral Prophylaxis (2) Dosing for Infant Zidovudine (ZDV) HIV Prophylaxis www.aidsetc.org

  6. Infant Antiretroviral Prophylaxis (3) • Infants born to mothers who did not receive antepartum ARV drugs • Standard 6-week course of ZDV, plus • 3 doses of NVP in the first week of life (AI) • 1st dose at birth • 2nd dose 48 hours later • 3rd dose 96 hours after 2nd dose • Begin regimen as soon as possible postdelivery www.aidsetc.org

  7. Infant Antiretroviral Prophylaxis (4) Weight Band Dosing for Infant Nevirapine (NVP) HIV Prophylaxis www.aidsetc.org

  8. Infant Antiretroviral Prophylaxis (5) • For complex scenarios, eg: • Infant born to a mother who received antepartum/ intrapartum ARV drugs but has suboptimal viral suppression at delivery • Infant born to a mother with ARV drug-resistant virus • Consult a pediatric HIV specialist for guidance on combination prophylaxis • Preferably before delivery • Counsel about risks and benefits (BIII) www.aidsetc.org

  9. Infant Antiretroviral Prophylaxis (6) • Management of breast-feeding infants of mothers diagnosed with HIV infection postpartum • Stop breast-feeding • Consult a pediatric HIV specialist • Postexposureprophylaxis vspreemptive therapy • Perform virologic testing in infants <18 months of age • At baseline; 4-6 weeks; 3 months; and 6 months postdiagnosisof maternal infection • HIV DNA PCR is the preferred test for infants receiving combination prophylaxis or preemptive therapy www.aidsetc.org

  10. Infant Antiretroviral Prophylaxis (7) Safety considerations: • Limited data on most ARVs in infants, particularly if given in combination • NRTIs: • ZDV generally safe, may cause transient anemia • 3TC + ZDV may increase hematologic toxicity • NVP: Rare cases of severe rash and hepatotoxicity; resistance may occur in infants who become HIV infected • Protease inhibitors not recommended for neonates • No PK data for most • LPV/r: Possible cardiac and other toxicity www.aidsetc.org

  11. Infant Antiretroviral Prophylaxis (8) • In premature infants • Dosing information is available for: • ZDV • NVP • Use of other ARV drugs cannot be recommended because of lack of dosing and safety data. (BIII) • Consult a pediatric HIV specialist for cases in which there is high risk of perinatal transmission in a premature infant. www.aidsetc.org

  12. Infant Antiretroviral Prophylaxis (9) The National Perinatal HIV Hotline 1-888-448-8765 Free clinical consultation onall aspects of perinatal HIV www.aidsetc.org

  13. Initial Postnatal Management of the HIV-Exposed Neonate (1) • Obtain a CBC with differential before initiation of ARV prophylaxis. (BIII) • Frequency of monitoring blood levels is based on: (CIII) • Gestational age and clinical condition of infant • Baseline values • ZDV dosage administered • Receipt of other ARV drugs • Concomitant medications • Maternal ARV regimen www.aidsetc.org

  14. Initial Postnatal Management of the HIV-Exposed Neonate (2) • Intensive monitoring may be considered for infants exposed to combination ARV regimes in utero or neonatally, including: (CIII) • Hematologic monitoring • Serum chemistry • Liver function • Bilirubin levels (ATV exposure) • Monitoring can coincide with timing for HIV diagnostic lab work. (CIII) www.aidsetc.org

  15. Initial Postnatal Management of the HIV-Exposed Neonate (3) • For infants receiving combination ZDV/3TC-containing ARV prophylaxis: (AI) • Recheck hemoglobin and neutrophil count 4 weeks after ARV initiation and/or at the time HIV diagnostic testing is performed. • Consider for infants receiving ZDV 4 mg/kg twice-daily dosing www.aidsetc.org

  16. Initial Postnatal Management of the HIV-Exposed Neonate (4) • Routine measurement of serum lactate is not recommended unless infant develops severe clinical symptoms. (CIII) • Especially neurologic symptoms • In symptomatic infants with significantly abnormal serum lactate levels (>5 mmol/L): • Discontinue ARV prophylaxis • Consult a pediatric HIV specialist for alternative prophylaxis www.aidsetc.org

  17. Initial Postnatal Management of the HIV-Exposed Neonate (5) • If hematological abnormalities are identified, considerations about continuing ARV prophylaxis include: (CIII) • Extent of abnormality • Related symptoms • Duration of prophylaxis • Risk of HIV infection • Availability of alternative interventions • May consider reducing therapy to 4 weeks. • Consult a pediatric HIV specialist. www.aidsetc.org

  18. Initial Postnatal Management of the HIV-Exposed Neonate (6) • Diagnostic HIV tests for infants: (AII) • HIV DNA PCR • Optimal test for diagnosis in the neonatal period • HIV RNA • Standard antibody tests cannot be used to diagnose HIV infection in infants • Detect maternal HIV antibodies up to 18 months www.aidsetc.org

  19. Initial Postnatal Management of the HIV-Exposed Neonate (7) • Virologic tests should be performed at: (AII) • 14-21 days, • 1 to 2 months, and • 4 to 6 months • Virologic tests at birth may be performed • If mother did not have good virologic control during pregnancy • If adequate follow-up cannot be assured www.aidsetc.org

  20. Initial Postnatal Management of the HIV-Exposed Neonate (8) • HIV infection in an infant is diagnosed by two positive virologictests on separate specimens. • HIV infection is excluded: • Presumptively by two negative virologic tests, one at age ≥14 days and one at age ≥1 month • Definitively(in non-breast-fed infants) by two negative virologic tests, one at age ≥1 month and one at age ≥4 months • Negative status may be confirmed by antibody testing at age 12-18 months • See guidelines for diagnosis of non-subtype-B HIV. www.aidsetc.org

  21. Initial Postnatal Management of the HIV-Exposed Neonate (9) • PCP prophylaxis should begin at age 4-6 weeks, after completion of ARV prophylaxis. (AII) • Unless HIV infection can be presumptively excluded • Evaluate and treat infants as indicated for transmittable maternal coinfections identified through history or physical evaluation. • HIV-exposed infants should follow the routine immunization schedule www.aidsetc.org

  22. Initial Postnatal Management of the HIV-Exposed Neonate (10) • Preventing HIV transmission to infants: • HIV-positive women should not breast-feed • Transmission of HIV in infancy may occur owing to the practice of premasticating foods • Health providers should: (AII) • Inquire about premastication with patients • Instruct HIV-infected caregivers to avoid the practice • Advise on safer feeding options www.aidsetc.org

  23. Long-Term Follow-Up of Infants Exposed to ARVs • Long-term data from infants exposed to ARVs in utero are insufficient. • Children with in utero/neonatal exposure to ARVs who develop significant organ system abnormalities of unknown etiology, particularly the nervous system or heart, should be evaluated or mitochondrial dysfunction. (CIII) • Follow-up of children with exposure should continue to adulthood owing to theoretical concerns for carcinogenicity of nucleoside analogues. (CIII) www.aidsetc.org

More Related