Professional Documents
Culture Documents
Guideline for
Management of Pediatric
HIV/AIDS
Ministry of Health
Royal Government of Bhutan
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Guideline for Management of Pediatric HIV/AIDS
ACKNOWLEDGEMENTS
The guideline was formulated with the core technical team of the follow-
ing officials:
Program Manager
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Guideline for Management of Pediatric HIV/AIDS
Chapter 1:
Introduction .................................................................................. 9-10
Chapter 2:
Clinical manifestations. ............................................................. 11 - 20
Chapter 3:
Staging and classification. ........................................................... 21 - 24
Chapter 4:
Management of newborns born to HIV-infected mothers. ....... 25 - 27
Chapter 5:
Management of HIV in children ............................................... 28 - 35
Chapter 6:
Diagnosis and treatment of OI in HIV infected children. ............36 - 54
Chapter 7:
HAART in Pediatric HIV Infection. ........................................... 55 - 60
Cahpter 8:
Care and support for hcildren living with HIV/AIDS. ................ 61 - 62
Annexure 1
Pediatric ARV drugs. .............................................................. 63 - 70
Annexure 2
Pediartrc forms ....................................................................... 71 - 77
Annexure 3
WHO classification of HIV infection ............................................. 78 - 80
Annexure 4
References. .................................................................................... 81
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Guideline for Management of Pediatric HIV/AIDS
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Guideline for Management of Pediatric HIV/AIDS
FOREWORD
Infected children differ from infected adults in several ways. The dis-
ease progresses much more rapidly in children, recurrent bacterial in-
fections are more common and children are more susceptible to oppor-
tunistic infections because of lack of prior immunity. In the absence of
treatment infected children will have a shorter life expectancy than
those with out infection.
However, we must not forget that the key to preventing HIV infection in
children clearly lies in preventing their parents from acquiring the dis-
ease. Increased attention must also be focused on strategies to prevent
mother to child transmission and the prevention of unwanted pregnan-
cies in HIV-infected mothers. The availability and the use of family plan-
ning for mothers infected with HIV/AIDS will also reduce the number of
infected children. HIV infected women should have access to informa-
tion, follow up clinical care and support including family planning and
nutritional support. Information and education efforts should be urgently
directed to the public, affected communities and their families.
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Guideline for Management of Pediatric HIV/AIDS
The HIV pandemic threatens to erode many of our hard earned gains
made in reducing infant and child mortality. The concerted efforts of
parents, care takers, health workers and policy makers will be crucial to
reducing the number of new infections and preventing deaths among
our children.
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Guideline for Management of Pediatric HIV/AIDS
PREFACE
The second component covers formula feeding techniques for the chil-
dren born to HIV infected mothers. The National Policy for infant and
young child feeding in Bhutan recommends formula feeding in Bhutan.
Bhutan however, is an ardent believer of the benefits of the breast feed-
ing and is actively promoted in the general population. The issue of
whether breast feeding be recommended for infants born from HIV in-
fected mothers has been discussed in depth at the highest HIV/AIDS
policy body in the National for HIV/AIDS Commission.
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Guideline for Management of Pediatric HIV/AIDS
ABBREVIATIONS
ARV Antiretroviral
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 1
1. INTRODUCTION
Every day 8,500 children and young people around the world are in-
fected with HIV. As of the end of 2004, some 2.2 million children under
15 years were living with HIV. Many children were born to mothers with
HIV acquiring the virus around the time of birth or from breast feeding.
In the absence of any interventions, about a third of children born to HIV
infected mothers will be born with HIV or infected through breastfeed-
ing.
Children born with HIV have very high mortality. They are over four
times more likely to die by the age of two than children born without HIV.
HIV has contributed to a rise or stagnation in under- five mortality in
several countries in Africa, but is not the only factor behind these
trends.
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 2
CLINICAL MANIFESTATIONS OF HIV/AIDS IN
CHILDREN
2.1 DIFFERENCE IN PEDIATRIC AND ADULT
HIV-INFECTION
Overall progression of disease is more rapid in
children.
Immune system is more immature with higher
CD4 counts
Recurrent invasive bacterial infections are more
common in children.
Disseminated CMV, Candida, Herpes Simplex and
Varicella zoster are more common.
LIP occur almost exclusively in children.
CNS infections are common.
Peripheral neuropathy, Myopathy is rare in children.
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Guideline for Management of Pediatric HIV/AIDS
Children who acquire the infection due to transfusion blood tend to have
an incubation period ranging up to 4 years.
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Guideline for Management of Pediatric HIV/AIDS
A. FAILURE TO THRIVE
Failure to thrive is very common feature of pediatric HIV
-infection.
HIV-infection has adverse effect on the growth of the
infected children.
Can manifest as early as 4-6 months of age in perinatally
infected children, which has been correlated with high
viral load in mothers.
The cause factors are low birth weight, decreased energy
intake, diarrhea, malabsorption, and chronic disease of
the heart, kidney and lungs, micronutrient deficiencies,
neuroendocrine abnormalities and repeated episodes of
infection.
Length/height and weight, which are anthropometrical
parameters that represent growth in children in children
needs to be, monitored regularly for early detection and
treatment.
B. HEPATOMEGALY
Hepatomegaly is a common GI manifestation of pediatric
HIV-infection.
It is likely to be caused by the replication of the virus in
the reticuloendothelial tissue of the liver.
Development of hepatomegaly within 3 months of age
(in perinatally acquired HIV-infection) has prognostic
significance since it is known to be associated with rapid
progression of the disease.
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Guideline for Management of Pediatric HIV/AIDS
C. LYMPADENOPATHY
HIV, after initial viremia, gets trapped in the lymph
nodes and also multiples there.
The replication of HIV in the nodes is the primary cause
of lymphadenopathy.
Other important conditions commonly associated with
HIV-infection that can give rise to generalized
lymphadenopathy in HIV -infected children include
tuberculosis, disseminated infections with other
mycobacterial species, viral infections with CMV,
Epstein -Barr virus(EBV) and malignancies like
lymphoma and lymphosarcoma.
D. CHRONIC DIARRHEA
Diarrhea is a very common clinical manifestation of
HIV-infected infants and children in developing
countries.
The causes are infections, other inflammatory processes
and malabsorption of carbohydrate and fats.
It is believed that HIV replication in the gastrointestinal
mucosa can lead to diarrhea itself leading to HIV
enteropathy.
Opportunistic enteric infections with common organisms
like Candida, Cryptosporodium, Cytomegalovirus,
Giardia, Isosporabelli and salmonella can cause chronic
diarrhea.
Persistent infection leads to prolonged diarrhea with
malabsorption and malnutrition.
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Guideline for Management of Pediatric HIV/AIDS
E. PAROTITIS
Parotitis occurs as recurrent or chronic hypertrophic
parotitis.
The parotid swelling evolves gradually in patients with
HIV disease. It may be due to the direct infection of parotid
gland by HIV or due to lympocytic infiltration of the gland.
The swelling may be unilateral or bilateral but is classically
painless and recurrent.
F. SKIN MANIFESTATIONS
HIV -infection in children is associated with a number of
skin manifestations. These can be due to infectious or
non-infectious causes.
Viral, bacterial and fungal infections have been frequently
reported in HIV infected children, common skin diseases
may present with unusual skin lesions such as Norwegian
scabies, disseminated, confluent and large lesions of
Molluscum contagiosum.
Infectious disorders and Non-infectious Disorders and
lesions lesions
Viral infections: Seborrhic dermatitis, atopic
Herpes simplex, Herpes dermatitis
Zoster, CMV Generalized dermatitis,
Molluscum contagiosum, Nutritional deficiency
warts Eczema, Psoriasis, Drug
Fungal infections: eruptions
Candida, Tinea, Eczema, Psoriasis, Drgu
Onchomycosis eruptions
Bacterial: impetigo Vasculitis
Others: Scabies Alopecia, Papular pruritic
eruptions
G. ORAL CANDIASIS
Oral candidiasis is the most common form of fungal
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Guideline for Management of Pediatric HIV/AIDS
TUBERCULOSIS
It is the most important opportunistic infection
encountered in children, occurring at a higher CD4
count when the immune-deficiency is comparatively
less advanced.
Mycobacterium avium intercellular (MAC) causes
disseminated and usually non-pulmonary disease and
is important cause of morbidity in HIV-infected
children. A CD4 count < 100 cells/mm3 has been
recognised as a primary risk factor for this infection.
Respiratory viruses like respiratory syncytial virus,
measles, parainfluenza, influenza, adenovirus,
rhinovirus and corona virus, cause prolong and severe
disease.
Fungal infections due to histoplasmosis,
coccidiodomycosis and aspergillosis present similarly.
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 3
CLINICAL STAGING AND CLASSIFICATION
3.1 WHO CLINICAL STAGING OF HIV/AIDS FOR IN
FANTS AND CHILDREN
The following WHO definitions are designed for use in developing coun-
tries. They are based on clear clinical markers and do not require any
of the diagnostic technology which is likely to be lacking in countries
where such resources are limited.
CLINICAL STAGE 1
Asymtomatic.
Persistent generalized lymphadenopathy.
CLINICAL STAGE 2
Hepatomegaly.
Papular pruritic eruptions.
Seborrhoeic dermatitis.
Fungal nail infection.
Angular cheilitis.
Lineal gingival erythema.
Extensive molluscum contagiosum.
Extensive human papilloma virus infection.
Recurrent oral ulcers.
Parotid enlargement.
Herpes zoster.
Recurrent RTI( otitis media, otorrhoe or sinusitis) twice or
more in any six-month period.
CLINICAL STAGE 3
Unexplained moderate malnitrition not adequately
responding to standard treatment.
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Guideline for Management of Pediatric HIV/AIDS
CLINICAL STAGE 4
Unexplained severe wasting, or severe mlanutrition or stunting
not responding to standard treatment.
Pneumocytis pneumonia. (PCP)
Recurrent severe presumed bacterial infections (two or more
episodes in one year). e.g. meningitis, empyema. Pyimyositis,
bone or joint infection, bacteremia)
Chronic herpes simplex infection( orolabial or intraoral lesions of
more than one month or visceral of any duration.
Oesophageal candidiasis.
Extrapulmonary TB.
Kaposis sarcoma.
Toxoplasmosis of the brain.
Cryptococcal meningitis.
HIV encephalopathy, as defined by the Centers for Disease Con-
trol and Prevention.
CMV retinitis and CMV of an organ other than liver, spleen or
lymph nodes.
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suppression
suppression
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 4
MANAGEMENT OF NEWBORN BABIES BORN
TO HIV INFECTION MOTHER
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Guideline for Management of Pediatric HIV/AIDS
4.5 IMMUNIZATION
Almost all the baby are asymptomatic at birth even if they have been
infected with HIV from the mother. Hence the routine immunizations as
per the national guidelines must be carried out.
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Guideline for Management of Pediatric HIV/AIDS
Follow up visits:
At age 6, 10, and 14 weeks on the occasion of routine immunizations.
At 6 weeks prophylaxis for PCP should be started.
Thereafter once a month up to 1 year.
Every 3 months from 1 year to 5 years.
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 5
MANAGEMENT OF HIV INFECTED CHILDREN
5.1 DIAGNOSIS OF HIV INFECTION
A child is suspected to have HIV infection if he has clinical features
described earlier in chapter 2 and 3. It is then confirmed by a HIV anti-
body testing after 18 months of age.
5.2 EVALUATION
History taking and physical examination are essential for:
Classifying the patient as asymptomatic, and for detecting the onset of
disease. It should be done every month till the infants are 12 months old
and then every 3 months till their HIV status is confirmed. This can be
done at the same time that the baby attends the MCH clinic for growth
monitoring.
Early diagnosis of common infections, which tend to be more severe
and persistent and do not respond as well to treatment in HIV -infected
children
Early diagnosis of opportunistic infections and complications of HIV
disease.
History should include the following
When and where was the diagnosis of HIV made.
What is the childs possible source of HIV infection.
What are the current symptoms and concerns of the child.
Past medical history of symptoms, known diagnosis and treatments given.
Known allergies to drugs or other substances or materials.
History of recurrent infections in the past.
History of possible contact with TB.
Current and prior opportunistic infection (OI) prophylaxis.
Current and previous ART.
Attitude to and readiness to commence ART.
Ability of the care-giver to adhere to OI prophylaxis and other drugs (such as
TB therapy) in the past.
Ability to keep scheduled appointments in the past.
Family history e.g. other immediate family members especially mother with
known HIV infection and their state of health.
Psychological and financial and family support.
History of drug and alcohol use in older children.
Enquire about toxicity and side effects of ART.
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A) ESSENTIAL:
HIV serology ( confirmed by ELISA)
CBC
CD4 counts and percentage
Blood chemistry: RFT/electrolyte, LFT, Blood sugar,
lactate level, lipid profile
Chest X-ray
PPD
B) SUPPLEMENTARY:
Urine microscopy
Hepatitis markers
Cultures: blood, urine, sputum and fungi
Untrasound and other imaging techniques as per the
clinical pictures.
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Guideline for Management of Pediatric HIV/AIDS
5.7 IMMUNIZATION
Immunization schedule recommended by Royal Government of Bhutan
for all other children is to be followed for HIV exposed infants. The main
stress is to immunize asymptomatic children as per schedule and to
with hold the live vaccines (BCG and OPV) in symptomatic immuno-
compromised HIV children.
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Guideline for Management of Pediatric HIV/AIDS
CHAPTER 6
MANAGEMENT OF OPPORTUNISTIC INFECTIONS (OIs)
The natural history of opportunistic infections among children might dif-
fer from that observed among HIV-infected adults. Many opportunistic
infections in adults are secondary to reactivation of previously acquired
opportunistic pathogens, which were often acquired before HIV infec-
tion at a time when host immunity was intact. However, opportunistic
infections among HIV-infected children more often reflect primary infec-
tion with the pathogen. In addition, among children with perinatal HIV
infection, the primary infection with the opportunistic pathogen is occur-
ring after HIV infecteion is established when the childs immune system
might already be compromised. This can lead to different manifesta-
tions of disease associated with the pathogen among children than
among adults. For example, young children with TB are more likely to
have extra pulmonary and disseminated infection than adults, even
without concurrent HIV infection.
Multiple difficulties exist in making laboratory diagnosis of various infec-
tions in children. Diagnosis is often compounded by a childs inability to
describe the symptoms of disease. For infections where the primary
diagnostic modality is the presence of antibody (e,g,, the hepatitis vi-
ruses and cytomegalovirus), the ability to make a diagnosis in young
infants is complicated by transplacental transfer of maternal antibody
that can persist in the infant for 12 - 15 months. Assays capable of di-
rectly detecting the pathogen are required to definitively diagnose such
infections in infants. In addition, diagnosing the etiology of lung infec-
tions among children can be difficult because they do not generally
produce sputum, and more invasive procedures might be needed.
Opprotunistic infections are the hallmarks of immunodeficiency. OIs are
related to the rising plasma viral load and decreasing CD4 counts. It is
essential to diagnose OIs, since acute infections could be life threaten-
ing. Effective prophylactic regimens against several OIs will reduce the
frequencies of OIs and also improve the survival rates. It is therefore
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Guideline for Management of Pediatric HIV/AIDS
CLINICAL MANIFESTATIONS:
Presents with tetrad of tachypnea, dyspnea, cough
and fever.
Physical examination reveals tachycardie, respiratory
distress, accelerating tachypnea and diffuse
retractions
Auscultation does not reveal any characteristic
findings.
RADIOLOGICAL FINDINGS:
Sings of hyperinflation with peribronchial thickening,
progressing to bilateral alveolar or interstitial
infiltrates, spreading outwards from the hila.
Further progression results in bilateral air-space
disease with air-bronchograms,cavities, pleural
effusion and pneumothorax.
Consider the diagnosis if PCP in a patient of HIV with
spontaneous pneumothorax.
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Guideline for Management of Pediatric HIV/AIDS
DIAGNOSIS:
Can be confirmed by Wright-Giemsa staining of
induced sputum or samples obtained by Broncho-
alveolar lavage (BAL). trophozoites and intracystic
sporozoites can be demonstrated in the stained
specimen.
TREATMENT:
It is a medical emergency and treatment should not
be delayed.
Drug therapy
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Guideline for Management of Pediatric HIV/AIDS
IN A HIV-INFECTED CHILD:
If the child is on ARV therapy, cotrimoxazole can be stopped
ONLY when evidence of immune restoration has occurred.
This can be assumed where the child is over 18 months of
age and CD4% >15% at two measurements, at least
3-6 months apart. If a CD4 count is not available,
cotrimoxazole should not be stopped before a full 6 months
of successful adherence to ARV therapy, and then only
when clinical evidence of immune restoration is present.
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Guideline for Management of Pediatric HIV/AIDS
DOSAGE OF COTRIMOXAZOLE:
Syrup is recommended in very young children up to 10-12 kg
Dosage of 6-8 mg/kg once daily should be used
Single strength adult tab( sulfamethoxazole 400mg
and trimethoprim 80mg)
Up to 10 kg =half of a standard adult tablet
10-25 kg = one tablet
>25kgs = two tablets
Use weight for dosage rather than body surface
If the child is allergic to cotrimoxazole, dapsone( 2mg/kg/d
orally, max. dose 100mg/day) is the best alternative.
FOLLOW UP:
Assessment of tolerance and adherence: cotrimoxazole
prophylaxis should be routine part of care of HIV infected
children, and be assessed at all regular clinic visits or
follow up visits by health workers and/or other members
of multidisciplinary care teams.
Initial clinic follow-up in children is suggested monthly,
and then every 3 months, if cotrimoxazole is well tolerated.
6.2 TUBERCULOSIS
One of the most common HIV related OI is
tuberculosis.
HIV increases the susceptibility to both the primary
infections as well as to reactivation of tuberculosis
-infection due to depressed cell-mediated immunity.
Primary infection due to contact with an
infectious case is common in children with
HIV-infection.
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Guideline for Management of Pediatric HIV/AIDS
CLINICAL FEATURES
Fever, cough, and weight loss, night sweats and
malaise are common clinical findings
Extrapulmonary disease may involve other tissues
and organs as the central nervous system,
lymph nodes and mastoid.
The manifestations in extensive tuberculosis are
related to the system involved. The features include
miliary tuberculosis, hepatosplenomegaly,
lymphadenopathy, tuberculosis meningitis, and
genitor-urinary tuberculosis.
DIAGNOSIS
Clinical history and features
PPD, Mantoux test- is considered positive if the
induration is 5mm or more.
Chest radiology: may show features of lobar or
multi-lobar infiltrates or diffuse interstitial disease or
hilar adenopathy.
Sputum AFB/gastric aspirate.
Tissue specimen where ever possible( Lymph
node biopsy, pus and CSF)
TREATMENT:
Because of high risk of dissemination in children < 4 years treatment
with ATT should be started as soon as TB is suspected
Give DOTS therapy at least for the first two months.
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Guideline for Management of Pediatric HIV/AIDS
PROPHYLAXIS:
Children with positive PPD test but without any other
manifestation of active disease should receive INH for
12 months.
Children with recent contact with an infectious
tubercular patient.
Children with a history of prior untreated or inade-
quately treated past tubercular infection
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Guideline for Management of Pediatric HIV/AIDS
CLINICAL FEATURES
High grade fever, weight loss, abdominal pain and
anemia are common.
Night sweats, diarrhea, malaise, hepatomegaly,
osteomyelitis, meningoencephalitis, soft tissue
abscess
DIAGNOSIS
Blood culture ( positive in > 90% )
Bone marrow, liver and lymph node biopsy
Anaemia and neutropenia with non specific CXR
changes or diffuse and focal infiltrates, cavitatory
lesions and hilar adenopathy.
TREATMENT
Combination therapy with a minimum of 2 drugs is
recommended
Clarithromycin 15 mg/kg/day in two divided doses
( max. 500mg/day ) + Ethambutol single dose of
15 20 mg/kg.
In severe infection either add Amikacin 15 30 mg/
kg/day in two divided doses or one may add
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Guideline for Management of Pediatric HIV/AIDS
TREATMENT:
Initial therapy with Amphotericin B 0.5-1mg/kg I.V.
once a day with Flucytosine ( 50 150 mg/kg/day
orally in four divided doses for 14 days or till clinical
involvement Followed by Fluconazole 8- 12 mg/kg/
day orally (maximum 400 mg/day) for eight to
ten weeks.
PROPHYLAXIS:
Life long secondary prophylaxis with Fluconazole
3-6 mg/kg/day orally
Alternative is Amphotericin IV, 0.5 0.7 mg/kg/day,
one to three times per week.
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Guideline for Management of Pediatric HIV/AIDS
DIAGNOSIS
Pseudohyphea seens on a KOH stained preparation
Candida can be isolated from blood culture
Endoscopy and biopsy for esophageal candidiasis
Esophageal
candidias Fluconazole 3-6mg/kg OD ( max 200mg ) X 14d
Disseminated
candidiasis Amphotericin B 0.5 1 mg/kg/day IV X 21 d
PROPHYLAXIS :
Children with recurrent infections should be given prophylaxis
with oral fluconazole
Fluconazole 3-6 mg/kg/day oral, daily
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Guideline for Management of Pediatric HIV/AIDS
DIAGNOSIS:
Typical clinical appearance
Tzanck smear
HSV 1 & 2 antigen by immunoflorescence
TREATMENT :
Neonates Acyclovir 45 60 mg/kg IV inn 3 div. doses for
2 3 weeks
Older children with severe infections Acyclovir 30mg/kg/d
in 3 div doses for 14 21 days
Genital /primary gingivostomatitis may receive oral acyclovir
80mg/kg/d in 3 div doses for 10 days
PROPHYLAXIS :
Oral Acyclovir 80mg/kg/d in 2-3 div doses for recurrent or
severe relapses or if they have severe and slowly healing
lesions.
6.7 VARICELLA ZOSTER VIRUS (VZU)
Clinical features
Classically presents with fever and a generalized pruritic
vesicular rash
Persistent lesions ( i.e., continued appearance of new lesion
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Guideline for Management of Pediatric HIV/AIDS
for more than one month after onset ) are seen in HIV infected
children
In chronic infections the lesions turn verrucous and necrotic.
Pneumonia, hepatitis, and encephalitis seen with severe
immunosuppression
DIAGNOSIS
Typical rash
VZV IgM antibody, and virus culture
PCR and Tzanck smear
TREATMENT
Acyclovir 30mg/kg/day in three div doses, IV for 7 10 days
or till no new lesions appear, whichever is later.
Foscarnet 120 180mg/kg/day in 3 div doses, if no response
to Acyclovir
DIAGNOSIS
Classical presentation of painful vesicular eruption with dermatomal in-
volvement Viral antigen from the skin kesions
TREATMENT
Treat patients with neurologic complications, and
disseminated infections
Acylovir 30mg/kg/day in three div doses, IV for 7 10 days no
new lesions appear, whichever is later.
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Guideline for Management of Pediatric HIV/AIDS
DIAGNOSIS
CMV retinitis is diagnosed by fundoscopy
CMV esophagitis by endoscopic findings of small and
confluent ulcers.
Sigmoidoscopy for CMV colitis which reveals diffuse areas
of erythematic, submocosal hemorrhage and mucosal
ulcerations.
Serologic tests have limitations. Does not differentiate
between new and old infection.
TREATMENT
Ganciclovir, 10mg/kg/din 2 div doses, IV over 1-2 hrs for
14 21 days or
PROPHYLAXIS
Life long prophylaxis after an episode of end organ disease
Ganciclovir, 5mg/kg/d IV, 5 days a week or
Foscarnet 90 120 mg/kg/d IV as a single daily dose or
Oral ganciclovir 30 mg/kg, three times a day
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Guideline for Management of Pediatric HIV/AIDS
6.10 TOXOPLASMOSIS
Congenital infection is common
Features of congenital infection include low birth weight,
microcephaly, hydrocephalous, hepatosplenomegaly and
chorioretinitis.
CNS toxoplasmosis can present as headache, fever, changes
in mental status, seizures, psychosis, focal neurological
deficits, and cranial nerve palsies.
DIAGNOSIS
Congenital toxoplasmosis can be diagnosed by detecting
Toxoplasma-specific IgM, IgA, in neonatal serum within the
first 6 months of life or persistence of specific IgG antibody
beyond age 12 months.
A presumptive diagnosis of CNS toxoplasmosis is based
on clinical symptoms, serologic evidence of infection, and
the presence of a ring enhancing granulomas on imaging
studies of the brain.
Definitive diagnosis of Toxoplasma encephalitis requires
histologic or cytologic confirmation by brain biopsy
TREATMENT
Congenital infection should be treated with 12 months and
CNS toxoplasmosis for 6 weeks after resolution of all signs
and symptoms of active disease.
Pyrimethamine, loading dose of 12 mg/kg body weight/day
for 2 days, then 1 mg/kg/day for 2 6 months, followed by
by 1 mg/kg administered three times a week for the rest of
the year plus Sulfadiazine 100mg/kg followed by 85 120
mg/kg/day in 4 divided doses
Folinic acid ( calcium leucovorin ) 5 10 mg/kg/day, three
times a week to prevent megaloblastic anaemia secondary
to pyrimethamine.
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Guideline for Management of Pediatric HIV/AIDS
PROPHYLAXIS
Infants previously treated for congenital toxoplasmosis
An episode of CNS toxoplasmosis should be followed by
life long suppressive therapy.
Sulfadiazine 85 120 mg/gk/day in 2 4 divided doses
plus pyrimeythamine 1mg/kg/day plus leucovorin 5mg/kg
every three days.
Alternative, Clindamycin 20 30 mg/kg in 4 divide doses
plus Pyrimethamine 1mg/kg/day plus Leucovorin 5mg/kg/
day, three times a week.
DIAGNOSIS
Blood culture, CSF examination, CXR, culture from abscess,
bone scan.
TREATMENT
Bacteremia Vancomycin and a third generation
cephalosporin
Pneumonia Cefotaxime, Ceftriaxone, ampicillin sulbactum.
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Guideline for Management of Pediatric HIV/AIDS
CHEMOPROPHYLAXIS
Daily prophylaxis with TMP-SMX protects against serious
bacterial infections.
Administration of IVIG (Intravenous Immunoglobulin ) 400
mg/kg/month is recommended in children with Hypogamma
globulinemia, and in children with a history of two or
moreinvasive bacterial infections in one year especially
for those who have failed or are intolerant to antibiotic
prophylaxis.
Another indication for IVIG is chronic bronchiectasis that is
sub optimally responsive to antimicrobial and pulmonary
therapy.
6.12 DIARRHEA
Chronic diarrhea is common in children
May become a life threatening event
May be due to infections with bacteria, protozoa, viral and
also as a side effect of drugs
Large watery stools with abdominal pain
Chronic diarrhea may cause malnutrition
Fever dehydration with loss of appetite may be seen
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ENTAMOEBA HISTOLYTICA.
Diagnosis :stool trophozoites or cysts
Serological test ( positive with tissue invasion )
Endoscopy and biopsy if stool test is negative
Treatment for gut infection diloxanide furoate
For invasive disease give metronidazole 30mg/kg/d in
three div. doses plus chloroquine.
Giardial lamblia
Trophoizoites and cysts seen in stool, duodenal aspirates.
Treat with metronidazole 15mg/kg/d in 3 div doses for 5- 7
days or
Furazolidine 6 mg/kg/d in 4 div doses for 10 days
ROTAVIRUS
Elisa in stool sample
Supportive treatment only needed
CAMPYLOBADCTER
Stool culture or blood culture
Serology for ELISA
Treat with Erythromycin 30 50 mg/kg/d in 4 div doses for
7 days
Azithromycin 10mg/kg on day 1 followed by 5mg/kg OD for 5
days
Ciprofloxacin 20mg/kg/d twice a day for 5 days
SHIGELLA
Stool culture
Endoscopic evidence of deep mucosal ulceration and or
pseudomembranes.
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Guideline for Management of Pediatric HIV/AIDS
SALMONELLA
Stool culture
Cefotaxime 150 200 mg/kg/d in 3- 4 div doses
Ceftriaxone 100mg/kg/d in 1- 2 doses IV
Ciprofloxacin 15 30 mg/kg/d Oral or IV
Duration is for 10 to 14 days
CLOSTRIDIUM DIFFICILE
Isolation of organism in stool
Detection of toxin in stool by ELISA
Colonoscopy show pseudomembranes nodules
and plaques
Treat by stopping the current antibiotic
Metronidazole 30mg/kg/d in 3 div doses plus vancomycin
25 50 mg/kg/d in 4 div doses
Duration of therapy is for 7 10 days.
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CHAPTER 7
HAART IN PEDIATRIC HIV INFECTION
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a. First line:
AZT + 3TC + NVP
or
AZT + 3TC + EFV
(If the child does not tolerate NVP then switch with EFV in children more
than three years or more than 20 kgs)
b. Second line:
d4T + 3TC + NVP/EFV
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CHAPTER 8
CARE AND SUPPORT FOR CHILDREN LIVING WITH
HIV/AIDS
As increasing numbers of mothers and children become infected, the
infant and childhood mortality will be seriously affected. 20 30 % of
HIV infected children who survive the first year will die before 5 years of
age. The moral and humanitarian obligations to provide appropriate
care and support to children infected with HIV and their families lies
with health care providers and the government. The main goal should
be to provide a good quality of life.
To contain the disease to its minimum manifestation
To encourage the normal growth and development of the child
To support the child to use his maximum potential and
abilities
To prevent physical and psychological consequences
To create awareness for preventative behaviour in adoles -
cents.
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(AZT,ZDV, retro- Caps: 100mg; 2mg/kg 6 hourly mia, nausea, syrub not well tol-
2
vir 250 mg IV: 120 mg/m /6 headaches, myo- erated in older
day cephalopathy.
Reduce in hepatic
dysfunction
Lamivudine Syrub 10mg/ml Neonate < 30 Headache, pain Well tolerated can
(3TC) Epivir Tab. 150mg days: 2mg/kg/ abdo, pancreatitis, give with food
small amount of
immediately tak-
en
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Guideline for Management of Pediatric HIV/AIDS
Stavudine (d4T) Oral solution < 30 kg : 1mg/kg/ Headache, GI up- Large volume of
Zerit 1mg/ml Capsule dose twice daily set, rash, periph- solution Capsules
food(stable in so-
if refrigerated)
frigerated; stable
to be stored on
glass bottle
Non- Nucleoside Reverse Transcriptase Inhibitors(NNRTIs)
Nevirapine Oral suspension 15-30day: 5mg/ Rash 5-10% can Avoid use with
(NVP) 10mg/ml kg/dose once daily treat, if stevens- rifampicin
Tablets: 200mg x 2 weeks, then johnsin-STOP. Store susupension
120mg/m2 dose Elevated liver in room tempera-
twice daily then enzymes ture, must shake
200mg/m2/dose well
twice daily Can give with food
Tablets crushed and
can be mixed with
food and water and
taken immediately
MUST WARN
PARENTS ABOUT
RASH.
Efavirenz (EFV) Syrub 39mg/ml 10-15 kg- 200mg CNS Toxicity- som- Dose may be best
Tablets 50, 100, OD nolence, abnormal given at night
200, 600mg 15-20kg- 250mg; dreams,
20-25 kg- 300mg;
>40kg-600mg;
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GENERAL INFORMATION
Serial Number:.............................RN.................Date:........../............/........
Name:.............................................Age:........years Sex: M F
Address:.........................................................................................................
.........................................................................................................................
Parents: Father:...........................................Mother.....................................
Occupation:
Father.............................................................Mother....................................
Education:
Father.............................................................Mother.....................................
Immunization: Complete Incomplete Not given
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GENERAL EXAMINATION
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SYSMATIC EXAMINATION
Head/ENT/Eye: Skin/mucous membrane:
Respiratory system: Cardiovascular system:
GI system: Central nervous system:
Genitor-urinary system: Joints:
Development milestones
Motor: normal delayed
Sensory normal delayed
Social: normal delayed
LABORATORY INVESTIGATION
OTHER INVESTIGATIONS:
X-RAY CHEST PPD:
USG
Stool Urine
CSF Cultures:
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Name: RN:
Antibiotic
ATT
Anti-diarrheal
Antifungal
Anti Viral
Others;
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ANNEXURE.3
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Two major and two minor signs are required in the absence of
known causes of immunosuppression.
Major signs are defined as: Minor signs are defined as:
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ANNEXURE 4.
Reference:
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