care of the neonate

CARE OF THE NEONATE

August 20122 www.aidsetc.org

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)

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)


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.



Age Zidovudine Dose Duration

≥35 weeks’ gestation at birth 4 mg/kg/dose PO twice dailyIf unable to tolerate oral agents:3 mg/kg/dose IV every 12 hours

Birth through 6 weeks

Give first dose as close to the time of birth as possible (preferably within 6 to 12 hours)

≥30 to <35 weeks’ gestation 2 mg/kg/dose PO every 12 hours or 1.5 mg/kg/dose IV every 12 hours.At age 15 days: increase to 3 mg/kg/dose PO every 12 hours or 2.3 mg/kg/dose IV every 12 hours

<30 weeks’ gestation 2 mg/kg/dose PO every 12 hours or 1.5 mg/kg/dose IV every 12 hoursAfter age 4 weeks: increase to 3 mg/kg/dose PO every 12 hours or 2.3 mg/kg/dose IV every 12 hours


Dosing for Infant Zidovudine (ZDV) HIV Prophylaxis


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



Weight Band Nevirapine Dosage Timing and Duration

Birth weight: 1.5-2 kg 8 mg TOTAL for each dose

3 doses in the first week of life:1st dose as soon as possible postdelivery and within 48 hours of birth2nd dose 48 hours after the 1st dose3rd dose 96 hours after 2nd dose

Birth weight: >2 kg 12 mg TOTAL for each dose

Same


Weight Band Dosing for Infant Nevirapine (NVP) HIV Prophylaxis


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)



Management of breast-feeding infants of mothers diagnosed with HIV infection postpartum Stop breast-feeding Consult a pediatric HIV specialist

Postexposure prophylaxis vs preemptive therapy Perform virologic testing in infants <18 months of age

At baseline; 4-6 weeks; 3 months; and 6 months postdiagnosis of maternal infection

HIV DNA PCR is the preferred test for infants receiving combination prophylaxis or preemptive therapy



Safety considerations:Limited data on most ARVs in infants, particularly if given in combinationNRTIs:

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 infectedProtease inhibitors not recommended for neonates

No PK data for most LPV/r: Possible cardiac and other toxicity



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.



The National Perinatal HIV Hotline

1-888-448-8765

Free clinical consultation onall aspects of perinatal HIV


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



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)



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



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



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.



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



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



HIV infection in an infant is diagnosed by two positive virologic tests 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.



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



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


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)


care of the neonate

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