Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine

2. Collagen-Vascular Illnesses

3. Chromosomal Abnormalities

4. Generalized
--R/O Sepsis - Case Histories
--Approach to Neonatal Group B Strep Infection

HIV: What the Primary Care Physician Needs to Know

Chris White, MD

Introduction: Almost all pediatric HIV infections are vertically acquired, therefore, the pediatrician is most likely to be asked to manage the infant of HIV infected mothers.

Perinatal Decisions: If woman is known to be HIV positive, should attempt to reduce the risk factors for transmitting the virus to the newborn:

1. Viral Load in Mother: The higher the load, the more the danger to the baby.  Try and reduce the viral load as low as possible in the mother before delivery (Management of this most commonly by a physician specializing in HIV) Rx:  All mothers should receive AZT during peripartum period unless drug toxic
2. Vaginal delivery: While controversial C. Section seems to help reduce infection
3. Breastfeeding: Quite controversial in third world countries where there is high incidence of HIV infection (risk = increased by 10% per each month baby breastfed); problem: If don’t breast feed there, death from malnutrition a concern.

Diagnostic Approach to the Baby of an Infected Mother:

1. HIV ELISA test will be positive for as long as 15 months of age, because of passively acquired maternal IgG antibody.  Therefore must use antigen test to diagnose:

However, until the HIV ELISA is negative, can not be conclusive that child doesn’t have HIV infection; in fact, need to have two consecutive HIV ELISA tests negative three months apart to say child does not have HIV.

2. DNA PCR test: A negative test after 3 months of age means the child is probably not infected.  In the newborn: 38% of infected children are positive by 48 hours of age, 93% of infected children are positive by 14 days.  If a DNA PCR test is positive, repeat the test.

• Continue to test every 3 months until 2 consecutive DNA PCRs are negative.
• If positive at 18 mos, repeat PCR.

Therapeutic Approach to the Baby of an Infected Mother:

1. Give AZT (10 mg/cc: 2 mg/kg po q 6 hours; if IV, give 1.5 mg/kg q 6 hours)) - begin within 8-12 hours after birth and continue until six weeks of age.
2. At 6 weeks of age, discontinue AZT and start Septra prophylaxis at a dose of 150mg/meter squared/day given bid on Monday, Wednesday and Friday.  his med continues until HIV ruled out or 1 year of age.

Vaccines Given to an Infected HIV Child:

1. No live viruses: e.g. Oral Polio, nasal influenza.
2. Varicella is OK to give if CD 4 percentage is >25%.  Give 2 doses 3 months apart.
3. MMR is OK to give unless severely immunocompromised (CIC category 3).  Give second dose 4 weeks after first dose if immune status OK.
4. All other vaccines OK.
5. All infected children should get annual Influenza vaccine (injection).

When Should a Child be Referred to an ID Specialist? Refer all infected children so that antiretroviral Rx can be started.

Day Care and Schools: While tears and saliva can carry the virus, no evidence that ever transmitted in this way.  No obligation for the pediatrician to inform the school or day care about the child’s HIV status unless unusual situations exist where transmission can occur – such as aggressive biting, exudative skin lesions.  This can be a very difficult situation for both parent and pediatrician.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004