View
219
Download
0
Category
Preview:
Citation preview
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
1/71
Egyptian_Pediatric yahoo group
http://health.groups.yahoo.com/group/
egyptian_pediatric/
Egyptian_
http://health
eg
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
2/71
Answer Key: 1. D; 2. A; 3. B; 4. E; 5. B; 6. B; 7. D; 8. B; 9. E;10. B; 11. E; 12. E
ArticlesAsthma Epidemiology, Pathophysiology,
and Initial Evaluation331
Vanessa L. Hill, Pamela Runge Wood
Thinking About HIV Infection337Evelyn P. Simpkins, George K. Siberry, Nancy Hutton
Coping With Death350Jennifer S. Linebarger, Olle Jane Z. Sahler, Kelsey A. Egan
Index of Suspicion357Case 1: Daniel H. Reirden
Case 2: Alexandra N. Menchise, Brian Knox, Rani Gereige
Case 3: Tamara Howard, Erica L. Thomas, Rosina Connelly
Case 4: Sarah Tyler, Katie McPeak
Research and Statistics: Cohort Studies364Raquel G. Hernandez, Peter C. Rowe
Pediatrics in the Community:Bulletproof: Using Media as a Tool for Advocacy371 Alexander Zusman, Tricia Michels Tayama
In Brief Parental Monitoring andDiscipline in Middle Childhood366
Cholelithiasis and Cholecystitis368
Clarification369
Internet-Only Article
Abstract appears on page 370.The Floppy Infant: Evaluation of Hypotoniae66Dawn E. Peredo, Mark C. Hannibal
Cover Art Conteste77
Cover: The artwork on the cover of this month’s issue is
by one of the winners of our 2007 Cover Art Contest,
9-year-old Amelia Broman of St. Cloud, Minn. Amelia’s
pediatrician is Kelly Fandel, MD.
contentsPediatricsinReview Vol.30No.9September 2009
Editor-in-Chief: Lawrence F. Nazarian, Rochester, NY Associate Editors: Tina L. Cheng, Baltimore, MD
Joseph A. Zenel, Sioux Falls, SD Editor, In Brief: Henry M. Adam, Bronx, NY Consulting Editor, In Brief: Janet Serwint, Baltimore, MD Editor, Index of Suspicion:
Deepak M. Kamat, Detroit, MI Consulting Editor Online and Multimedia
Projects: Laura Ibsen, Portland, OR Editor Emeritus and Founding Editor:
Robert J. Haggerty, Canandaigua, NY Managing Editor: Luann ZanzolaMedical Copy Editor: Deborah K. KuhlmanEditorial Assistant: Sydney Sutherland
Editorial Office: Department of PediatricsUniversity of Rochester
School of Medicine & Dentistry 601 Elmwood Avenue, Box 777Rochester, NY 14642sydney_sutherland@urmc.rochester.edu
Editorial BoardHugh D. Allen, Columbus, OH Margie Andreae, Ann Arbor, MI Richard Antaya, New Haven, CT Denise Bratcher, Kansas City, MO George R. Buchanan, Dallas, TX Brian Carter, Nashville, TN Latha Chandran, Stony Brook, NY David Cornfield, Stanford, CA Joseph Croffie, Indianapolis, IN B. Anne Eberhard, New Hyde Park, NY Leonard Feld, Charlotte, NC Rani Gereige, Tampa, FL
Mark Goldstein, Boston, MA Lindsey Grossman, Baltimore, MD Patricia Hamilton, London, UnitedKingdom HalB. Jenson, Springfield, MA DonaldLewis, Norfolk, VA Gregory Liptak, Syracuse, NY Blaise Nemeth, Madison, WI John Pascoe, Dayton, OH ThomasT. Sato, Milwaukee, WI Sarah E. Shea, Halifax, Nova Scotia NancySpector, Philadelphia,PA Surendra K. Varma, Lubbock, TX
Publisher: American Academy of PediatricsMichael J. Held, Director, Division of Scholarly Journals and Professional Periodicals
Pediatrics in ReviewPediatrics in Review(ISSN 0191-9601) is owned andcontrolled by theAmericanAcademy of Pediatrics. Itis published monthlyby theAmericanAcademy of Pediatrics, 141NorthwestPointBlvd., ElkGroveVillage,IL 60007-1098
Statementsand opinions expressed in Pediatrics in Review arethoseof theauthorsandnot necessarily those of theAmericanAcademy of Pediatrics or itsCommittees.Recommendationsincluded in this publication do notindicate an exclusive courseof treatmentor serve as a standard of medical care.Subscription price for2009 forprint andonline/onlineonly:AAP Fellow$163/$124; AAPCandidate Fellow$153/$114;Nonmember $204/$159;Allied HealthorResident $152/$103. Institutionscall for pricing (866-843-2271). For overseasdelivery,add $95. Current singleissue price is $10 domestic,$12 international.Replacement issuesmust be claimed within 6 monthsfrom thedate of issue andarelimited to three percalendaryear.Periodicalspostage paid at ARLINGTONHEIGHTS, ILLINOIS and at additionalmailing offices.© AMERICAN ACADEMY OF PEDIATRICS, 2009. Allrightsreserved. Printed inUSA. No part maybe duplicated or reproduced withoutpermission of theAmerican Academy of Pediatrics.POSTMASTER: Send address changes to PEDIATRICS IN REVIEW , American Academy of Pediatrics Customer Service Center, 141 NorthwestPoint Blvd., Elk Grove Village, IL 60007-1098.
Pediatrics in Review Print Issue Editorial Board DisclosuresThe American Academy of Pediatrics (AAP) Policy on Disclosure of FinancialRelationships and Resolution of Conflicts of Interest for AAP CME Activities isdesigned to ensure quality, objective, balanced, and scientifically rigorous AAPCME activities by identifying and resolving all potential conflicts of interest beforethe confirmation of service of those in a position to influence and/or control CMEcontent.
Every individual in a position to influence and/or control the content of AAPCME activities is required to disclose to the AAP, and subsequently to learners whether the individual has relevant financial relationships with manufacturers of commercial products and/or services discussed in the CME activities.Each of the editorial board members disclosed that the CME content he/sheedits/writes may include discussion/reference to generic pharmaceuticals, off-labelpharmaceutical use, investigational therapies, brand names, and manufacturers, if applicable.None of the editors had any relevant financial relationships to disclose, unless notedbelow. The AAP has taken steps to resolve any potential conflicts of interest.
Disclosures● Richard Antaya, MD, FAAP, disclosed that he participates in the Astellas Pharma,
US, Inc., speaker bureau, advisory board, and clinical trials; and in the Novartisspeaker bureau.
● Joseph Croffie, MD, MPH, FAAP, disclosed that he has research grants andserves on speaker bureaus of Sucampo Pharmaceuticals (Lubiprostone), BraintreeLabs (Miralax Halflytely), Medtronics (Bravo pH Capsule), Tap pharmaceuticals(Prevacid).
● Leonard Feld, MD, MMM, PhD, FAAP, disclosed that he is a speaker for andcommittee member of a Pediatric Board Review Course (sponsored by AbbottNutrition) through the AAP New York Chapter.
● Hal B. Jenson, MD, MBA, FAAP, disclosed that he is a speaker and vaccineadvisory board member for Merck Vaccines as well as a speaker for SanofiPasteur.
● Donald W. Lewis, MD, FAAP, disclosed that he is a consultant for and has aresearch grant from Astra Zeneca and Merck; and that he has research grants
from Ortho McNeil, Lilly, Bristol-Myers Squibb, GlaxoSmithKline, andBoehringer Ingelheim Pharmaceutical.
The printing and production of Pediatrics in Review issupported, in part, through an educational grant from Abbott Nutrition, a division of Abbott Laboratories.
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
3/71
DOI: 10.1542/pir.30-9-3312009;30;331-336Pediatr. Rev.
Vanessa L. Hill and Pamela Runge WoodAsthma Epidemiology, Pathophysiology, and Initial Evaluation
http://pedsinreview.aappublications.org/cgi/content/full/30/9/331located on the World Wide Web at:
The online version of this article, along with updated information and services, is
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy ofpublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1979. Pediatrics in Review is owned,Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://pedsinreview.aappublications.org/cgi/content/full/30/9/331http://pedsinreview.aappublications.org/cgi/content/full/30/9/331http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://pedsinreview.aappublications.org/cgi/content/full/30/9/331
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
4/71
Asthma Epidemiology, Pathophysiology, andInitial Evaluation
Vanessa L. Hill, MD,*
Pamela Runge Wood,
MD†
Author Disclosure
Drs Hill and Wood
have disclosed no
financial relationships
relevant to this
article. This
commentary does not
contain a discussionof an unapproved/
investigative use of a
commercial
product/device.
Objectives After completing this article, readers should be able to:
1. Describe the underlying pathophysiology of asthma.
2. Discuss the role of atopy in the development of asthma.
3. Identify risk factors for death from asthma.
4. List conditions to be considered in the differential diagnosis of wheezing in children.
Introduction Asthma is a disease of airway inflammation characterized by hyperresponsiveness and
airflow obstruction that lead to symptoms such as cough and wheezing (Fig. 1). Child-
hood asthma continues to cause significant morbidity and burden in the United States.
This article reviews the pathophysiology, epidemiology, and recommendations for initial
evaluation of asthma. Recommendations are based on the 2007 Expert Panel Report 3:
Guidelines for the Diagnosis and Management of Asthma (“2007 Guidelines”). (1)
EpidemiologyPrevalence and Burden of Disease
The prevalence of asthma rose steadily from 1980 until the late 1990s, when it reached a
plateau. In 2007, 9% of children 0 to 17 years of age (6.7 million children) had asthma,
according to data from the National Health Interview Survey. The lifetime prevalence of
asthma in children is 13%. (2)
The burden of disease in the United States from pediatric asthma is alarming, according
to a recent report based on national surveys. In 2003, 12.8 million days of missed school
were attributed to asthma. In 2004, hospitalizations for asthma totaled 198,000 or 3% of
all pediatric admissions. Asthma resulted in 750,000 emergency department (ED) visits in
that same year (2.8% of all pediatric ED visits). Although children ages 0 to 4 years of age represent only a small proportion of the total asthma population, they account for a
sizeable proportion of the hospitalizations and ED visits. (3)
Natural HistoryThe natural history of asthma is variable. Most individuals who develop chronic asthma,
measured by a decrease in lung function and persistence of symptoms, have a genetic
predisposition. In addition, exposure of the airway epithelium to environmental insults in
such susceptible individuals contributes to the development, severity, and persistence of
asthma.
The Tucson Children’s Respiratory Study, a longitudinal
community-based study of 1,246 children who were fol-
lowed from birth until early adulthood, provides data on thenatural history of respiratory disease in children. (4) Data
from this study show that wheezing in the first 3 years after
birth often is associated with a lower respiratory tract infec-
tion, most commonly respiratory syncytial virus (RSV).
Thirty-two percent of all children have wheezing with acute
lower respiratory tract infections in the first year after birth,
17% in the second year, and 12% in the third year. More than
80% of infants who have a history of wheezing in the first
postnatal year do not wheeze after age 3 years.
*Assistant Professor of Pediatrics.†
Clinical Professor of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Tex.
Abbreviations
ED: emergency department
FEV 1
: forced expiratory volume in 1 second
Ig: immunoglobulin
IL: interleukin
RSV: respiratory syncytial virus
Th: T-helper
VCD: vocal cord dysfunction
Article allergy & immunology
Pediatrics in Review Vol.30 No.9 September 2009 331. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
5/71
The investigators also identified three distinct wheez-
ing phenotypes that occur during childhood. “Transient
wheezers” are those infants whose wheezing is associated
with one or more lower respiratory tract infections and
who cease to wheeze after 3 years of age. “Nonatopic
wheezers” are children who have relatively more reac-
tive airways, a higher incidence of previous RSV infec-
tion, and persistent wheezing after age 3 years, which may
resolve over time. “Atopic wheezers” are the group of
children who are most likely to develop persistent asthma.Theyhavehigher immunoglobulin E (IgE) concentrations,
are prone to allergen-mediated airway hyperresponsive-
ness, and have more profound lung function deficits at an
early age compared with “nonatopic wheezers.” In gen-
eral, 60% of children who have asthma are symptom-free
by adulthood. However, only 5% to 30% of children who
have severe asthma or asthma associated with atopy out-
grow their asthma by adulthood. (5)
Mortality and Health Disparities Although mortality rates have fallen since 1999, asthma
remains a preventable cause of death in children. In
2004, the mortality rate from
asthma was 2.5 per 1 million chil-
dren for a total of 186 deaths per
year. Therefore, it is crucial to iden-
tify children at risk of death from
asthma. In general, the rate of
death from asthma is higher in se-
vere, uncontrolled disease. Specific
risk factors include: one or more
life-threatening exacerbations of
asthma, severe asthma requiring
chronic oral corticosteroids, poor
control of daily asthma symptoms
requiring frequent short-acting
beta2 agonist medication, abnor-mal forced expiratory volume in
1 second (FEV 1), frequent ED
visits, low socioeconomic status,
family dysfunction, and patient
psychological problems. (6)
Racial disparities are significant
in asthma. Prevalence rates for
asthma are highest among Puerto
Rican and African American chil-
dren. Compared with white chil-
dren, African American children
have higher rates of ED visits butlower outpatient and ambulatory
visits. African American children
continue to have higher rates of mortality than other
children, despite a downward trend in overall asthma
mortality rates. (3) Such disparity reflects limited access
to outpatient health services compared with other chil-
dren. (7)
PathophysiologyInherent to asthma is airway inflammation that is medi-
ated by a variety of cell subtypes, resulting in hyper-
responsive airways, ultimately limiting airflow and causing variable symptoms. Initial airway bronchoconstriction is
followed by airway edema and exaggerated mucus pro-
duction, accompanied by airway hyperresponsiveness,
and followed by chronic changes in the airway epithelium
(airway remodeling). Current medical management tar-
gets various points along this continuum. However, no
clear evidence suggests that early or aggressive treatment
with anti-inflammatory medications, such as inhaled cor-
ticosteroids, can prevent airway remodeling.
Airway inflammation is mediated by a variety of cyto-
kines and chemokines (cytokines that are specific for
chemotaxis and activation of leukocytes). Cytokines are
Figure 1. Mechanisms underlying the clinical symptoms of asthma. Adapted from the
National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007.
allergy & immunology asthma epidemiology, pathophysiology, evaluation
332 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
6/71
produced by a number of cell types, including lympho-
cytes, eosinophils, and mast cells. Proinflammatory cyto-
kines (interleukin-4 [IL-4], IL-5, and IL-13), produced
primarily by the T-helper (Th)2 lymphocytes, are be-
lieved to trigger the intense inflammation of allergic
asthma. An imbalance between Th1 and Th2 lympho-
cytes (specifically, decreased Th1 activity with increased
Th2 activity) contributes to chronic inflammatory
asthma. Chemokines play a key role in inflammation.
These proteins recruit proinflammatory cells, including
Th2 lymphocytes, mast cells, neutrophils, and eosino-
phils. Eosinophils and mast cells have a distinct role in
asthma pathogenesis. These cell types produce proin-
flammatory cytokines as well as leukotrienes, which cause
bronchoconstriction.The airway epithelium is a target for infectious, nox-
ious, and environmental insults that cause injury via
influx of proinflammatory cells and cytokines (Fig. 2).
Both viral infections and airborne allergens can precipi-
tate a biphasic response that ultimately leads to asthma
symptoms. IgE plays a pivotal role in this process, as
shown by evidence that administration of anti-IgE
monoclonal antibodies reduces asthma symptoms and
improves lung function. (8) The IgE-mediated “early-
phase” or “immediate” response to an allergen challenge
causes mast cells and basophils to degranulate, precipi-
tating bronchospasm as well as the release of proinflam-matory cytokines and chemokines. This cascade of in-
flammatory responses results in the subsequent “late-
phase” obstruction of air flow, which occurs 4 to 12
hours following exposure to the environmental insult.
Bronchodilators can relax airway smooth muscle, if ad-
ministered during the initial period of bronchospasm.
However, due to the increased airway hyperresponsive-
ness and inflammation that occur with the late-phase
response, bronchodilator therapy is not as effective, and
anti-inflammatory medication is required.
Asthma also is characterized on a cellular level by
structural alterations in the airway epithelium. Airway
remodeling can occur and is associated with the follow-
ing changes in the underlying structural components of
the epithelium: mucous gland hyperplasia, thickening
of the epithelial basement membrane, fibrotic changes in
the sub-basement membrane, bronchial smooth muscle
hypertrophy, and eventually angiogenesis.
Clinical Aspects Asthma is characterized by intermittent, recurrent symp-
toms of airway obstruction that is at least partially revers-
ible. Common symptoms include cough (which may
be the only symptom), wheezing, difficulty breathing,
and “chest tightness.” Nighttime symptoms are com-
mon. In addition, symptoms often occur or worsen in the
presence of common asthma “triggers,” such as exercise,
changes in the weather, viral respiratory infections, and
exposure to allergens or airway irritants (eg, environmen-
tal tobacco smoke). To diagnose asthma, the physicianmust exclude other conditions. The diagnosis may be
particularly difficult in very young children because
wheezing is common in early childhood and many dis-
eases can cause symptoms similar to
those seen in asthma.
EvaluationInitial evaluation should begin with
a detailed medical history, in-
cluding the pattern of symptoms
and observed precipitating factors
(asthma triggers). Past medical his-tory should include information
about risk factors for asthma (par-
ticularly atopy), prior exacerba-
tions, treatments used, and their
effects. A positive family history of
parental asthma substantially in-
creases the risk of asthma in a child.
Evaluation also should include an
assessment of the impact of asthma
on the child and family. The phys-
ical examination of a child who has
asthma often yields normal find-
Figure 2. Cellular mechanisms involved in airway inflammation. ILinterleukin,
IgEimmunoglobulin E, LTB4leukotriene B4. From the National Asthma Education andPrevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management
of Asthma. 1997.
allergy & immunology asthma epidemiology, pathophysiology, evaluation
Pediatrics in Review Vol.30 No.9 September 2009 333. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
7/71
ings, although there may be signs of atopy, such as
eczema or allergic rhinitis, which are strongly associated
with asthma.
The 2007 Guidelines recommend objective measure-
ment of pulmonary function (spirometry) as part of the
initial evaluation. Most children older than age 6 or 7
years are capable of performing a forced expiratory ma-
neuver, if coached by an experienced technician. Some
centers can test children as young as 5 years of age.
Spirometry should be performed before and after admin-
istration of a short-acting bronchodilator. FEV 1 that
increases by 12% or more following the administration
of bronchodilators indicates reversible airway obstruc-
tion, even if baseline FEV 1 is normal. Spirometry results
may be normal, particularly in children who have mildasthma. Baseline chest radiography may be useful to rule
out other conditions, particularly in very young children
or in patients manifesting atypical signs and symptoms.
Differential DiagnosisThe differential diagnosis of asthma is broad and includes
upper airway disease as well as obstruction of large air-
ways and other causes of small airway obstruction. Upper
airway disease, such as allergic rhinitis or sinusitis, can
cause recurrent coughing, particularly at night, but often
has other signs or symptoms that help distinguish it from
asthma. Extrinsic or intrinsic obstruction of the largeairways (eg, tracheomalacia, vascular ring, mass, or for-
eign body) may present with signs and symptoms similar
to those of asthma. Specific findings, such as a change in
airway symptoms with position or failure of symptoms to
respond to usual asthma treatment, may be helpful in the
diagnosis. Individuals who have ingested a foreign body
often have a history of acute onset of symptoms follow-
ing a choking episode, but this history is more difficult to
elicit in very young children. Recurrent aspiration or
gastroesophageal reflux also can result in recurrent bouts
of coughing or other respiratory symptoms that might
be confused with asthma. A careful history that examinesthe pattern of symptoms and looks for evidence of
risk factors for reflux or aspiration, such as prematurity,
feeding difficulties, or neurologic impairment, may be
helpful.
Vocal cord dysfunction (VCD) presents with wheez-
ing or breathlessness associated with paradoxic vocal
cord adduction during inspiration and may be difficult to
distinguish clinically from asthma. Although VCD is a
distinct diagnosis, it also may coexist with asthma and
complicate its management. VCD, which is more com-
mon in adolescents and young adults, does not respond
to asthma medications and, therefore, should be in-
cluded in the differential diagnosis of atypical or difficult-
to-control asthma. The diagnosis may be suspected
based on clinical history and spirometry that shows a
flattened inspiratory loop. Definitive diagnosis usually is
made by a specialist and based on viewing of the vocal
cords during an episode.
A number of conditions that cause obstruction of the
small airways may result in wheezing or other symptoms
similar to those found in asthma. These include bronchi-
olitis, cystic fibrosis, congestive heart failure, and chronic
lung disease of prematurity. Recurrent episodes of bron-
chiolitis may occur in young children and sometimes are
difficult to distinguish from asthma. A detailed past med-
ical history and careful physical examination often help to
distinguish the latter three conditions from asthma. Asthma is particularly difficult to diagnose in infants
and toddlers. Recurrent wheezing episodes are common
in young children. Data from the Tucson Children’s
Respiratory Study showed that almost 50% of children
have at least onewheezing episode prior to age 6 years; in
most of these children, the wheezing is transient and
resolves prior to age 6 years. (4) These data were used to
build a “risk index” for asthma in young children. Spe-
cifically, children experiencing four or more episodes of
wheezing per year that last more than 1 day and affect
sleep are likely to develop asthma if they also have one
of the following major risk factors: 1) parental history of asthma, 2) atopic dermatitis, and 3) sensitization to
aeroallergens or two of the following minor risk factors:
1) sensitization to foods, 2) more than 4% eosinophilia,
or 3) wheezing apart from colds. According to the 2007
Guidelines, the young child who has a positive risk index
is at a high risk of developing asthma and should be
started on anti-inflammatory therapy.
In summary, asthma cannot be diagnosed based on a
single episode of wheezing, but rather requires observa-
tion of the pattern of symptoms over time. Individuals
manifesting atypical signs and symptoms or clinical
asthma that does not respond to asthma medications may
Summary
• The prevalence of asthma and the burden of diseaseremain high, despite efforts to improve publicawareness about and medical management of asthma.
• Asthma is a disease of airway inflammation that hasa variable natural history.
• Atopy is the most important risk factor for thedevelopment of asthma.
allergy & immunology asthma epidemiology, pathophysiology, evaluation
334 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
8/71
require additional diagnostic studies (eg, specialized im-
aging of the chest or bronchoscopy) and referral to a
pulmonary specialist for additional evaluation.
NOTE. An article on the management of asthma will
be published in next month’s issue of Pediatrics in
Review .
References1. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of
Asthma. Full Report 2007. NIH Publication 07-4051. Bethesda,
Md: National Heart, Lung, and Blood Institute; 2007. Available at:http://www.nhlbi.nih.gov/guidelines/asthma/. Accessed June 20092. Bloom B, Cohen RA. Summary health statistics for U.S. chil-dren: National Health Interview Survey, 2007. National Center forHealth Statistics. Vital Health Stat . 2009;10(239). Available at: www.cdc.gov/nchs/nhis.htm. Accessed June 2009
3. Akinbami LJ. The state of childhood asthma, United States,1980–2005. Advance Data from Vital and Health Statistics ; No
381. Hyattsville, Md: National Center for Health Statistics; 2006. Available at: http://www.cdc.gov/nchs/data/ad/ad381.pdf. Ac-cessed June 20094. Taussig LM, Wright AL, Holberg CJ, Halonen M, Morgan WJ,Martinez FD. Tucson Children’s Respiratory Study: 1980 topresent. J Allergy Clin Immunol. 2003;111:661–6755. Phelan PD, Robertson CF, Olinsky A. The Melbourne AsthmaStudy: 1964–1999. J Allergy Clin Immunol. 2001;109:189–1946. Strunk RC. The fatality-prone asthmatic child and adolescent.Immunol Allergy Clin North Am. 1998;18:85–977. McDaniel M, Paxson C, Waldfogel J. Racial disparities in child-hood asthma in the United States: evidence from the NationalHealth Interview Survey, 1997 to 2003. Pediatrics. 2006;117:e868–e8778. Busse W, Corren J, Lanier BQ, et al. Omalizumab, anti-IgE recombinant humanized monoclonal antibody for the treat-ment of severe allergic asthma. J Allergy Clin Immunol. 2001;108:184–190
PIR QuizQuiz also available online at pedsinreview.aappublications.org.
1. An 11-month-old boy presents with fever, runny nose, and difficulty breathing for 1 day. Physicalexamination shows an axillary temperature of 37.8°C, respiratory rate of 32 breaths/min, and heart rate of 110 beats/min. Diffuse expiratory wheezes are audible bilaterally. He had similar illness 2 months ago. Themother is concerned about her son developing asthma during his childhood. Which of the following is themost appropriate response to her concerns about her son?
A. If he has two more episodes of wheezing during the next year, his chances of having asthma duringchildhood are greater than 80%.
B. If he responds to bronchodilators such as albuterol, there is a greater than 80% risk that he will haveasthma during childhood.
C. If the respiratory infection is due to RSV, he should have less than a 20% risk of developing asthmaduring childhood.
D. More than 80% of infants who have a history of wheezing after respiratory infection in the first
postnatal year do not wheeze after age 3 years.E. More than 80% of infants younger than 1 year of age who have respiratory tract infections wheezeduring their illness.
2. A 3-year-old boy who has a previous history of allergic rhinitis and eczema presents to your office withcough and wheezing for 2 days. The symptoms started after he visited his uncle’s house and played with acat. Which of the following statements about his current state is true?
A. Airway inflammation has occurred due to action of cytokines and chemokines.B. Airway remodeling has occurred, characterized by mucous gland hyperplasia and bronchial smooth
muscle hypertrophy.C. Current illness represents the early phase of mast cell activation, causing bronchospasm.D. Eosinophils have been activated by IgE, causing IL-4 release.E. Th1 lymphocyte activation by IgA has caused airway hyperreactivity.
allergy & immunology asthma epidemiology, pathophysiology, evaluation
Pediatrics in Review Vol.30 No.9 September 2009 335. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
9/71
3. A 6-year-old girl is brought in for evaluation of nighttime cough and wheezing after being exposed to
secondhand smoke. A pulmonary function test (PFT) using a forced expiratory maneuver to display a flow-volume curve is ordered. Which of the following statements is most accurate regarding PFT in thissituation?
A. Flattening of the inspiratory portion of the flow volume loop and decreased forced vital capacitysuggest the presence of asthma.
B. Increase in FEV 1
by at least 12% after administration of a bronchodilator is indicative of asthma.C. Normal PFT indicates that the patient does not have airway hyperresponsiveness and, therefore, retesting
with a bronchodilator is unnecessary.D. PFT assessment in those younger than age 8 years is unreliable due to lack of patient cooperation.E. PFT should be performed after challenging the patient with secondhand smoke and retesting after
administration of a bronchodilator.
4. A 15-year-old girl who has a known history of asthma is hospitalized for exacerbations of cough,wheezing, and shortness of breath. Her asthma has become increasingly unresponsive to bronchodilatorsand corticosteroids in the past 5 years. Flow-volume loop using a forced expiratory maneuver showsflattening of the inspiratory loop. Flexible fiberoptic laryngoscopy shows adduction of vocal cords andnarrowing of the subglottic area during inspiration. Which of the following is the most likely diagnosis?
A. Laryngomalacia.B. Subglottic hemangioma.C. Subglottic stenosis.D. Tethered vocal cord.E. Vocal cord dysfunction.
Find it in September NeoReviews™
The American Academy of Pediatrics online neonatology journal at http://neoreviews.aappublications.org
Educational Perspectives: Modeling Expertise in Medical Education—Leonard/Anderson
Thrombocytopenia in the Neonatal Intensive Care Unit—Saxonhouse/Sola-Visner
Immune-mediated Neutropenia in the Neonate—Black/Maheshwari
Preeclampsia and Neonatal Neutropenia—Moallem/Koenig
Index of Suspicion in the Nursery —Arevalo/Wetzel/Cabrera
Strip of the Month: September 2009—Druzin/Peterson
allergy & immunology asthma epidemiology, pathophysiology, evaluation
336 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
10/71
DOI: 10.1542/pir.30-9-3312009;30;331-336Pediatr. Rev.
Vanessa L. Hill and Pamela Runge WoodAsthma Epidemiology, Pathophysiology, and Initial Evaluation
& ServicesUpdated Information
http://pedsinreview.aappublications.org/cgi/content/full/30/9/331including high-resolution figures, can be found at:
Subspecialty Collections
ial_issues_problemshttp://pedsinreview.aappublications.org/cgi/collection/psychosoc
Psychosocial Issues and Problemsy_disordershttp://pedsinreview.aappublications.org/cgi/collection/respirator
Respiratory Disorderslated_disordershttp://pedsinreview.aappublications.org/cgi/collection/allergy_re
Allergy and Related Disordersfollowing collection(s):This article, along with others on similar topics, appears in the
Permissions & Licensing
http://pedsinreview.aappublications.org/misc/Permissions.shtmltables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,
Reprints http://pedsinreview.aappublications.org/misc/reprints.shtml
Information about ordering reprints can be found online:
. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://pedsinreview.aappublications.org/cgi/collection/psychosocial_issues_problemshttp://pedsinreview.aappublications.org/cgi/collection/psychosocial_issues_problemshttp://pedsinreview.aappublications.org/cgi/collection/psychosocial_issues_problemshttp://pedsinreview.aappublications.org/cgi/collection/respiratory_disordershttp://pedsinreview.aappublications.org/cgi/collection/respiratory_disordershttp://pedsinreview.aappublications.org/cgi/collection/allergy_related_disordershttp://pedsinreview.aappublications.org/cgi/collection/allergy_related_disordershttp://pedsinreview.aappublications.org/misc/Permissions.shtmlhttp://pedsinreview.aappublications.org/misc/Permissions.shtmlhttp://pedsinreview.aappublications.org/misc/reprints.shtmlhttp://pedsinreview.aappublications.org/misc/reprints.shtmlhttp://pedsinreview.aappublications.org/misc/reprints.shtmlhttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://pedsinreview.aappublications.org/misc/reprints.shtmlhttp://pedsinreview.aappublications.org/misc/Permissions.shtmlhttp://pedsinreview.aappublications.org/cgi/collection/psychosocial_issues_problemshttp://pedsinreview.aappublications.org/cgi/collection/respiratory_disordershttp://pedsinreview.aappublications.org/cgi/collection/allergy_related_disorders
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
11/71
DOI: 10.1542/pir.30-9-3372009;30;337-349Pediatr. Rev.
Evelyn P. Simpkins, George K. Siberry and Nancy HuttonThinking About HIV Infection
http://pedsinreview.aappublications.org/cgi/content/full/30/9/337located on the World Wide Web at:
The online version of this article, along with updated information and services, is
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy ofpublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1979. Pediatrics in Review is owned,Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://pedsinreview.aappublications.org/cgi/content/full/30/9/337http://pedsinreview.aappublications.org/cgi/content/full/30/9/337http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://pedsinreview.aappublications.org/cgi/content/full/30/9/337
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
12/71
Thinking About HIV InfectionEvelyn P. Simpkins, MD,*
George K. Siberry, MD,
MPH,† Nancy Hutton,
MD§
Author Disclosure
Drs Simpkins, Siberry,
and Hutton have
disclosed no financial
relationships relevant
to this article. This
commentary does notcontain a discussion
of an unapproved/
investigative use of a
commercial
product/device.
Objectives After completing this article, readers should be able to:
1. Recognize the important role that the general pediatrician plays in the prevention,
detection, and care of human immunodeficiency virus (HIV)-infected and -affected
patients.
2. Select the proper HIV testing plan for pediatric and adolescent patients based on age,
history, and physical assessment.
3. List the clinical conditions suggestive of HIV infection.
4. Provide counseling to reduce risk behaviors as part of routine adolescent health care.
5. Discuss comprehensive primary care for HIV-exposed infants.
Case Studies
Case Study 1 A 20-year-old woman, who is a recent emigrant from Ethiopia, brings in her 4-month-old
infant for a health supervision visit. The baby has had no immunizations, and his mother
reports having had no prenatal care. She is breastfeeding exclusively. The infant’s 25-year-old
father recently died after being very sick for 2 years. The mother states that he had “bad lungs.”
What are your next steps?
Case Study 2 A 17-year-old honor student comes to your office with a maculopapular rash on his face, trunk,
palms, and soles. He also complains of a sore throat and fever and states that he recently
returned from visiting his grandmother in Georgia. During his visit, he went hunting with his
uncles and his grandmother’s dog. During the interview, which involves asking routine
psychosocial questions in a nonthreatening manner (Table 1) to elicit sensitive information, he states that he has been sexually active with women for 2 years
and with men for 6 months. He does not use condoms with
either. He denies any contacts with sick persons or substance
abuse, including injection drug use (IDU). What are your
next steps?
IntroductionThe epidemiology, diagnosis, prevention, and treatment of
HIV infection and acquired immunodeficiency syndrome
(AIDS) in the pediatric and adolescent population have
changed dramatically over the past 25 years. In countries that
have good resources, such as the United States, rates of new infections in infants have plummeted with the implementa-
tion of effective screening and prevention strategies. Chil-
dren born with HIV early in the epidemic now are surviving
into young adulthood, facing unpredicted challenges and
opportunities in their physical health and social and emo-
tional well-being. Today’s adolescents are acquiring HIV at
an alarming rate. The role of the pediatrician varies with the
type of practice, the prevalence of HIV in the local commu-
*Fellow in Adolescent Medicine, Division of General Pediatrics & Adolescent Medicine.†Assistant Professor of Pediatrics, Division of General Pediatrics & Adolescent Medicine & Division of Infectious Diseases.§Associate Professor of Pediatrics, Division of General Pediatrics & Adolescent Medicine, Johns Hopkins University School of
Medicine, Baltimore, Md.
Abbreviations
AIDS: acquired immunodeficiency syndrome
CCR5: chemokine coreceptor 5
CD4: a glycoprotein on the surface of T helper cells
EIA: enzyme-linked immunoassay
HIV: human immunodeficiency virus
IDU: injection drug use
MMR: measles-mumps-rubella
mRNA: messenger RNA MTCT: mother-to-child transmission
NNRTI: non-nucleoside reverse transcriptase inhibitor
NRTI: nucleoside reverse transcriptase inhibitor
OI: opportunistic infection
PCP: Pneumocystis jiroveci pneumonia
PCR: polymerase chain reaction
PI: protease inhibitor
Article infectious diseases
Pediatrics in Review Vol.30 No.9 September 2009 337. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
13/71
nity, and the ease of access to HIV specialty care and
consultation. All pediatricians should be prepared to
provide care for HIV-exposed newborns and their sib-
lings, to screen for and diagnose HIV infection in chil-
dren and adolescents, and to provide routine HIV pre-
vention counseling to adolescents. Many pediatricians
provide primary care for HIV-infected children and ad-
olescents in collaboration with HIV specialists (Table 2).
Epidemiology Worldwide, 33.2 million people live with HIV infection,2.5 million of whom are children younger than 15 years
of age. In 2007, 2.1 million AIDS deaths occurred, of
whom 330,000 were children. In the United States,
2,181 cases of AIDS were reported among children and
adolescents through age 24 years for the year 2006. Only
38 of these cases were in children younger than the age of
13 years, a sharp and steady reduction from the early
1990s when nearly 1,000 children annually were re-
ported as having AIDS. Clearly, the “pediatric” burden
of infection and disease now rests in the adolescent
population. Many children who had HIV at birth in the
1980s and early 1990s now are adolescents and youngadults living with HIV/AIDS. In addition, the number
of new cases of AIDS reported is increasing in all age
categories within the 13- to 24-year-old population.
Despite widespread availability of HIV testing and effec-
tive treatment, it is estimated that 25% of people living
with HIV/AIDS do not know that they are infected, a
proportion that increases to nearly 50% for infected
adolescents.
PathogenesisUnderstanding the basics of the HIV viral life cycle can
help pediatricians to employ HIV laboratory tests confi-
dently and to understand the current approach to HIV
prevention and treatment. HIV is a lentivirus in the
retrovirus family. Susceptible hosts are infected when the
virus enters the body and binds to CD4 receptors on host
T lymphocytes. Through a complex process of specific
HIV glycoprotein binding to host T-lymphocyte CD4
receptor and chemokine coreceptor 5 (CCR5) corecep-
tors, HIV fuses its envelope with the lymphocyte cell
membrane. Viral RNA and enzymes such as reverse
transcriptase enter the host cell, and the viral RNA isreverse transcribed into DNA. Viral DNA then enters the
nucleus of the host cell and is integrated into the cellular
genome.
When the host cell is activated, transcription takes
place, allowing viral DNA to be converted to genomic
and messenger RNA (mRNA). mRNA is translated into
viral proteins that combine with copies of genomic RNA
to become complete virions that subsequently are re-
leased from the host cell. The cycle of infection, replica-
tion, and release continues rapidly in the newly infected
host, creating billions of virions per day.
This initial viremic phase precedes antibody response
Table 1.
HEEADSSS* Interview forAdolescents
HomeEducation and employmentEatingActivitiesDrugsSexualitySuicide/depressionSafety
*The mnemonic HEEADSSS reminds the clinician of important as-pects of an adolescent’s life that require inquiry. Sensitive informationshould be elicited in a nonthreatening manner.
Table 2.
The Pediatrician’s Role inHIV Care
Health Maintenance Care
HIV-exposed newbornsImmunizationsGrowth and nutritional statusNeurodevelopment
Acute and Chronic Illness Care
Clinical syndromes suggestive of underlying HIV infection
Common problems in HIV-infected infants, children,and adolescents
Collaboration With HIV Specialist
Evaluation and stagingAntiretroviral treatmentPrevention of opportunistic infections
Counseling and Support
Primary and secondary HIV preventionCoping with diagnosis and prognosisAdherence with care and treatmentSchool and sports participationTransition to adult health careAdvance care planning and palliative care
Universal Precautions–Standard Precautions
infectious diseases HIV infection
338 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
14/71
and is the period of highest infectivity due to the very
high viral load. During this time, dissemination of the
virus in the body and seeding of lymphoid organs is
widespread. The newly infected person may experience
acute retroviral syndrome, characterized by fever, lymph-
adenopathy, rash, myalgia, arthralgia, headache, diar-
rhea, oral ulcers, leukopenia, thrombocytopenia, and
transaminitis. During this “window period” between
host cell infection and host antibody response, an in-
fected person has a negative HIV antibody test result, but
HIV RNA testing results are positive. Seroconversion,
the demonstrated presence of HIV antibody, may occur
as early as 10 to 14 days after infection but usually occurs
within 3 or 4 weeks. Nearly all patients seroconvert
within 6 months of acquiring the infection. Infection with HIV is lifelong because HIV infects long-lived
memory T cells.
Preventing HIV Transmission to Children andAdolescentsHIV infection is transmitted by two principal modes in
the pediatric age group: mother-to-child and behavioral.
Mother-to-child transmission (MTCT) can occur ante-
partum through transplacental transfer; intrapartum
through exposure to maternal blood, amniotic fluid, and
cervicovaginal secretions during delivery; and postpar-
tum through breastfeeding. MTCT is preventable inalmost all cases by the proper use of combination anti-
retroviral therapy to achieve an undetectable viral load in
the mother, intrapartum maternal zidovudine, neonatal
zidovudine, and safe replacement infant feeding.
In addition, elective cesarean section prior to the
onset of labor can reduce MTCT risk in women who
have persistent viremia due to lack of or ineffective anti-
retroviral therapy during pregnancy. In the United
States, MTCT now occurs in fewer than 2% of births to
HIV-positive women, a decrease from 25% in nonbreast-
fed infants prior to the routine use of antiretroviral
therapy for the prevention of MTCT. It is important toremember that some infected infants escaped detection
early in the United States epidemic and now are being
identified as “new” cases in the adolescent age group.
Adolescents are exposed to HIV through risky behav-
iors that involve the exchange of infected blood or se-
men, such as unprotected sex (homosexual and hetero-
sexual) or injection drug use with sharing of needles or
syringes. Factors that increase the risk of sexual transmis-
sion include traumatic sex (voluntary or involuntary), in
which the genital, anal, or oral epithelium is compro-
mised (with those reporting receptive anal sex at highest
risk); active genital ulcer disease in either partner; and
(for females) douching before sex. Adolescent females
are at even higher risk than adult women of acquiring
sexually transmitted infections, including HIV, because
of the presence and vulnerability of the cervical ectro-
pion, an area of endocolumnar cells on the ectocervix
that regresses into the endocervical canal as the adoles-
cent matures. Behaviors that increase the likelihood of an
adolescent male or female being exposed to an HIV-
positive sexual partner include exchanging sex for money
or drugs, having multiple sex partners, and using recre-
ational drugs, including alcohol.
Studies of discordant partnerships (one person has
HIV infection, the other does not) reveal that consistent
and correct use of condoms made of latex, polyurethane,
or other synthetic materials offers a high degree of pro-tection from HIV and other sexually transmitted infec-
tions spread by the exchange of body fluids (as opposed
to infections spread by direct contact with lesions, such as
herpes simplex).
Testing for HIV Infection: Who, What,When?
The TestsSeveral laboratory tests are approved for screening and
diagnosing HIV infection (Table 3). The pediatrician
must select the correct test based on the patient’s age and
the clinical indication (Table 4). Most commercially available tests detect HIV antibody. For patients older
than age 18 months, the confirmed presence of antibody
to HIV is diagnostic of HIV infection. Standard HIV
antibody testing is performed on a blood specimen in
two steps: screening enzyme-linked immunoassay (EIA)
is performed and if reactive, a confirmatory test such as
Western blot is performed. Both steps must be positive
for the overall test result to be reported as positive.
Table 3. HIV TestsAntibody Tests in Laboratories
Enzyme-linked immunosorbent assayWestern blotImmunofluorescence assay
Antibody Tests in Clinical Settings (Rapid Tests)
BloodSaliva
Viral Detection Tests in Laboratories
DNA polymerase chain reaction (PCR) (qualitative)RNA PCR (quantitative)
infectious diseases HIV infection
Pediatrics in Review Vol.30 No.9 September 2009 339. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
15/71
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
16/71
out. One of the tests looks for HIV. Have you ever heard
of that?”
The most important guideline is never lie . Partial
truthfulness can be supplemented at later visits or at older
ages. Deliberate misinformation, even under the guise of
protecting the child, leads to loss of trust and is very
difficult to undo.
Screening Pregnant WomenUniversal HIV counseling and voluntary HIV testing
using an opt-out approach is the recommended standard
of care for all pregnant women in the United States. This
practice provides the opportunity for HIV-positive
women to access HIV care for their own health and to
prevent HIV transmission to their babies. The opt-outapproach informs all pregnant women receiving care that
an HIV test will be performed unless she opposes testing.
Initial testing is performed early in pregnancy. Repeat
testing is recommended in the third trimester (before
36 weeks’ gestation) for women who live in high HIV
prevalence areas or for women who have specific high-
risk factors (exchange sex for money or drugs, IDU,
sexual partner who engages in IDU, new diagnosis of
sexually transmitted infection during pregnancy).
For women who have not received prenatal care,
intrapartum testing should be offered by using rapid test
kits or expedited EIA. Mothers who decline screening atany of these opportunities should be offered testing again
at every opportunity, including rapid antibody testing in
the immediate postpartum period. Practitioners also can
offer rapid antibody testing of newborns as an indicator
of HIV exposure when the mother’s status cannot be
determined. In most cases, maternal consent is needed
for testing newborns, but some states allow testing of
high-risk newborns without consent.
Testing HIV-Exposed InfantsInfants born to HIV-positive mothers should undergo
specific diagnostic testing; HIV DNA or RNA PCR should be used as part of their health maintenance care.
Testing is recommended at age 14 to 21 days, at 1 to 2
months, and again at 4 to 6 months. Due to the low
sensitivity of tests in the first 48 hours after birth, testing
is optional at birth. If performed, blood samples from the
umbilical cord should not be used because of possible
contamination with maternal blood. In nonbreastfed
infants, the sensitivity of HIV DNA PCR increases to
93% by 14 days of age. By 28 days, the sensitivity in-
creases to 96% and the specificity is 99%. Sensitivity and
specificity of the HIV RNA assay are similar. Any positive
test requires repeat confirmatory testing as soon as pos-
sible. Some practitioners use HIV DNA PCR for initial
testing and HIV RNA assay for confirmatory testing.
HIV infection is reasonably excluded when results of
two virologic tests are negative, the first at 14 days or
older and the second at 1 month of age or older. Defin-
itive exclusion requires negative results for two virologic
tests, the first at age 1 month or older and the second at
4 months of age or older. In older infants for whom early
testing was not performed, an alternate strategy is to
confirm the absence of HIV antibody. If infection al-
ready has been excluded definitively, HIV antibody test-
ing between 12 and 18 months of age to confirm the loss
of maternal antibody is optional.
Breastfeeding causes continued HIV exposure and is
not recommended in the United States where safe re-placement (formula) feeding can be provided. Testing
should continue throughout the period of breastfeeding
and for 6 months after cessation when an infant is breast-
fed.
Testing Children and AdolescentsHIV antibody tests are used for screening and diagnosis
in children older than age 18 months. All children of
HIV-positive mothers should be screened for HIV infec-
tion regardless of age or healthy appearance. Children or
adolescents who present with clinical conditions sugges-
tive of HIV infection should undergo HIV testing as partof the diagnostic evaluation, regardless of risk history.
All adolescents should be offered HIV testing as part
of routine health care. Annual testing is recommended
for those at high risk of acquiring HIV infection. Rapid
tests offer the advantage of providing test results at the
same visit. HIV-negative individuals can be reassured
and counseled to avoid future HIV exposure. HIV-
positive individuals can be engaged immediately into
care and support.
If a practitioner suspects acute infection or acute
retroviral syndrome, he or she should order HIV anti-
body and nucleic acid testing (HIV RNA) to look forevidence of infection. A positive nucleic acid test result in
the presence of a negative or indeterminate antibody test
result is consistent with acute HIV infection. Antibody
testing is recommended 10 to 12 weeks later to confirm
seroconversion.
Evaluation and Staging of the HIV-PositivePatient
Patients who have positive HIV test results should be
referred to an HIV specialist for comprehensive evalua-
tion (Table 5) so the clinical and immunologic stage of
disease can be assessed and treatment recommended.
infectious diseases HIV infection
Pediatrics in Review Vol.30 No.9 September 2009 341. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
17/71
Initial evaluation of an HIV-infected pediatric patient
should include the mother’s medical history, child’s
medical history, family history, and social history. A com-
prehensive physical examination should be performed
and documented, including a developmental evaluation.
Assessment of HIV-infected adolescent patients (gener-
ally, 11 years of age and older), as for all adolescents,
should include a sexual history, substance use history,
and sexual maturity staging.
Initial laboratory testing in an HIV-positive patient
should include CD4 percentage and absolute cell counts,
plasma HIV RNA concentration (viral load), HIV geno-
type to assess for baseline resistance mutations, complete
blood count with differential count, serum chemistries
with liver and renal function tests, a lipid profile, andurinalysis. For children younger than 5 years of age, CD4
percentage is the preferred test for monitoring immune
status because the absolute CD4 cell count (number of
CD4 cells/mm3) in this age group varies with age-
related changes in absolute lymphocyte count. Screening
for hepatitis B and C infection as well as for tuberculosis
is recommended for all HIV-infected patients. In addi-
tion, sexually active adolescents should be screened for
Chlamydia infection, gonorrhea, syphilis, and human
papillomavirus infections. In contrast to the guidelines
for cervical cancer screening in healthy women, cervical
Papanicolaou smears are indicated routinely in all sexu-
ally active, HIV-infected adolescent girls, with colpos-
copy recommended for evaluation of abnormal results.
Similarly, most experts perform anal Pap smears in HIV-
infected adolescent men who have sex with men and
HIV-infected sexually active women; anoscopy is recom-
mended for evaluation of abnormal results.
HIV infection is a multisystem disease; clinical mani-
festations range from asymptomatic to complications
affecting virtually every organ system (Table 6). The
Centers for Disease Control and Prevention classification
system designates clinical categories based on the pa-
tient’s medical history and immunologic function cate-gories based on CD4 percentage (Table 7). This infor-
mation permits an estimated risk for future morbidity
and mortality and provides a rationale for instituting
specific opportunistic infection prophylaxis and initiating
or deferring antiretroviral therapy.
HIV-specific TreatmentAntiretroviral Therapy
The goal of anti-HIV therapy is to maximize the quality
and longevity of life through:
●
Complete suppression of viral replication (goal of non- detectable viral load )● Preservation or restoration of immunologic function
(goal of normal CD4 percentage or count )● Prevention of or improvement in clinical disease (goal
of asymptomatic state)
National treatmentguidelines for HIV-infectedchildren
and adolescents are updated routinely and are available on
the Internet (http://www.aidsinfo.nih.gov/Guidelines/).
Current recommendations are summarized in the text and
in Table 8. The pediatric treatment guidelines updated in
2008 recommend antiretroviral treatment for all infected
infants (12 months old); simplifies treatment initiationrecommendations into three age categories (12 months
old, 1 to 4 years old, and 5 years old) instead of four;
places greater emphasis on simplified, age-based CD4
thresholds for treatment initiation than on viral load; and is
consistent with adult guidelines for initiation of antiretrovi-
ral treatment in children 5 years of age and older. Clinical
and immune statuses are key predictors of morbidity and
mortality and form the basis for these recommendations.
Viral load is more useful for monitoring adherence and
effectiveness of therapy than as an indicator of when to
initiate antiretroviral therapy.
Treatment is recommended for: AIDS or severe symp-
Table 5. Evaluation and StagingHistory
Physical Assessment
Laboratory Assessment
Confirm HIV infectionHIV RNA (viral load)HIV resistance profile (genotype)CD4 percentage and absolute countComplete blood count with differential countChemistry panel (liver transaminases, bilirubin,
electrolytes, urea nitrogen, creatinine, calcium,phosphorus, glucose, cholesterol, triglycerides,amylase, lipase)
Coinfections: cytomegalovirus, Toxoplasma, hepatitisB and C, varicella
Urinalysis (dipstick and microscopic)
Tuberculin skin test
In sexually active individuals, screen for gonorrhea,Chlamydia infection, syphilis
Consider chest radiography, electrocardiography, dual-energy x-ray absorptiometry scan for bone mineraldensity
infectious diseases HIV infection
342 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
18/71
Table 6. Relative Frequency of Clinical Conditions in Untreated HIV Infection
Body System or Illness Category* Specific Conditions
Relative Frequency
Common Uncommon
Infections: recurrent, severe, or Recurrent or chronic otitis, sinusitis Cunusual (opportunistic) Recurrent or severe pneumonia C
Recurrent or severe bacteremia COpportunistic infections, such as PCP, MAC, invasive candidal
infectionsC
Lymphoreticular system Generalized lymphadenopathy CHepatomegaly CSplenomegaly CParotid enlargement CLymphoid interstitial pneumonitis C
Growth Failure to thrive CWeight loss, wasting C
Stunting CDelayed puberty C
Neurologic Neurodevelopmental delay or regression CAbnormal tone (increased or decreased) CGait disturbance CPeripheral neuropathy UStroke U
Pulmonary Bacterial pneumonia CLymphoid interstitial pneumonitis CBronchiectasis UPneumothorax U
Cardiovascular Cardiomyopathy UPericardial effusion UConduction abnormalities UHypertension U
Vasculopathy UGastrointestinal Gastritis CDuodenitis CHepatitis UPancreatitis UCholecystitis UDiarrhea CGastrointestinal bleeding UAbdominal pain C
Renal Proteinuria CRenal tubular acidosis URenal failure UHypertension U
Hematologic Anemia CNeutropenia CThrombocytopenia C
Dermatologic Seborrhea CEczema CUrticaria UZoster CHerpes simplex infections CTinea corporis, capitis, unguium CBacterial infections CMolluscum contagiosum CWarts (HPV) C
Genital/Reproductive HPV-related dysplasia (cervical, anal) CPelvic inflammatory disease CDelayed puberty C
*Some conditions belong to more than one category. HPV human papillomavirus, MACMycobacterium avium complex, PCPPneumocystis jiroveci pneumonia
infectious diseases HIV infection
Pediatrics in Review Vol.30 No.9 September 2009 343. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
19/71
toms, CD4 percentage of less than 25% (1 to 4 years) or
absolute CD4 count of less than 350 cells/mm3 (5 years
and older) regardless of symptoms, all infected infants
younger than 12 months of age, and all pregnant adoles-
cents.
Treatment is considered for: patients whose HIV
RNA is more than 100,000 copies/mL and who have
mild or absent symptoms and adequate CD4 cells (CD4
percentage of more than 25% [1 to 4 years] or absolute
CD4 count of more than 350 cells/mm3 [5 years and
older]).
Treatment can be deferred for: mild or absent symp-
toms and adequate CD4 values (CD4 percentage of
more than 25% [1 to 4 years] or absolute CD4 count of
less than 350 cells/mm3 [5 years andolder]) and RNA of
less than 100,000 copies/mL.
Antiretroviral therapy should be planned and moni-
tored in collaboration with an HIV
specialist. Strong evidence sup-
ports the use of triple-drug com-
bination antiretroviral therapy to
maximize virologic response and
minimize the emergence of viral
resistance. Initial therapy consists
of three drugs from two catego-
ries: one non-nucleoside reverse
transcriptase inhibitor (NNRTI)
OR protease inhibitor (PI) PLUS
two nucleoside or nucleotide
reverse transcriptase inhibitors
(NRTIs).
Important issues to consider whenselecting specific drugs include:
● Age, weight, sexual maturity stage of patient● Baseline HIV resistance pattern● Likelihood of developing resistance to selected drugs if
patient has difficulty adhering to the regimen (low
versus high barrier to resistance)● Likelihood of becoming pregnant while taking selected
drugs (eg, efavirenz)● Ease of administration (formulation, schedule, food
restrictions)
Planning treatment collaboratively with the patient
and family strengthens the therapeutic relationship and
promotes successful adherence and HIV control. Enlist-
ing adult support in the home is beneficial regardless of
the patient’s age. Frequent clinical follow-up with viral
load testing allows the clinician to identify problems early
and help patients and families find successful solutions.
Table 7. HIV Clinical Classification System
Clinical CategoriesN No symptoms*A Mild symptoms (eg, generalized
lymphadenopathy)B Moderate-to-severe symptoms
(eg, thrombocytopenia)C AIDS-defining conditions (eg,
Pneumocystis jiroveci pneumonia)
Immune Categories1 Normal CD4 >25%2 Moderate suppression CD4 15% to 24%3 Severe suppression CD4 350 cells/mm3
TREAT TREAT RNA100,000 copies/mLCONSIDER
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
20/71
Patients in whom the virus shows no drug resistance and
in whom therapy is initiated with currently available
medicines should achieve a nondetectable viral load
within 3 to 6 months. Failure to achieve this goal
strongly suggests suboptimal adherence to the recom-
mended regimen rather than viral resistance.
Once HIV infection is controlled on a stable regimen,
most patients are seen every 3 to 4 months for routine
monitoring of viral load, CD4 cell response, and clinical
status, including evaluation for potential medication ad-
verse effects or toxicities. Patients who experience treat-
ment failure have additional treatment options, includ-
ing new drugs in existing classes (PIs, NNRTIs, NRTIs)
as well as new drug classes such as entry inhibitors (fusion
inhibitors and CCR5 antagonists) and integrase inhibi-tors.
Preventing Opportunistic InfectionsThe profound immunodeficiency caused by uncontrolled
HIV infection allows serious and life-threatening infections
to occur in children and adolescents. Evidence supports the
primary prevention of common opportunistic infections
(OIs) based on age and CD4 guidelines. Full recommen-
dations are available at http://aidsinfo.nih.gov.
Pneumocystis jiroveci pneumonia (PCP) is the most
common OI. Cotrimoxazole is recommended for all
HIV-exposed infants until HIV infection is reasonably excluded, for all HIV-infected infants until age 12
months, and for HIV-infected children and adolescents
older than 1 year of age whose CD4 values fall into the
severe immune suppression category (CD4 percentage
15% or CD4 count 200 cells/mm3).
Primary prevention of Mycobacterium avium complex
by using azithromycin or clarithromycin is recom-
mended at lower CD4 values (6 years old with CD4
count of 50 cells/mm3; ages 2 to 5 years with CD4
count of 75 cells/mm3; 1 to2 years with CD4 count of
500 cells/mm3; 1 year old with CD4 count of
750 cells/mm3
).Toxoplasmosis is less common in children than in
adults, but its prevention with daily cotrimoxazole is
recommended in HIV-infected children and adolescents
who are Toxoplasma immunoglobulin G-seropositive
and have severe immunosuppression (CD4 percentage
15% for children 6 years old; CD4 count100 cells/
mm3 for children 6 years old).
ImmunizationsThe 2009 immunization schedule for HIV-exposed in-
fants and for HIV-infected infants, children, and adoles-
cents is the same as for their healthy peers, with only a few
exceptions. Patients who have severely symptomatic ill-
ness or CD4 percentages of less than 15% or CD4 counts
of less than 200 cells/mm3 should not receive measles-
mumps-rubella (MMR) or varicella vaccines due to the
risk of opportunistic disease from the live attenuated
virus strains in the vaccines. HIV-infected children who
have higher CD4 counts should receive MMR and vari-
cella separately, not as the combined MMR-V. The
higher titer of varicella in MMR-V has not been tested for
safety in HIV-infected children. Annual influenza immu-
nization is recommended for all children older than age 6
months, but only the killed, injectable formulations of
the influenza vaccine are recommended for HIV-infected
children and adolescents.
HIV-infected children and adolescents need certainadditional vaccines and doses. Pneumococcal polysac-
charide vaccine is recommended in addition to the reg-
ular pneumococcal conjugate vaccine series. Specific and
comprehensive recommendations for immunizations in
HIV-infected children, adolescents, and adults are avail-
able at http://aidsinfo.nih.gov/.
Counseling and SupportPrimary and Secondary Prevention of HIV Infection
Health education messages to avoid HIV infection andto prevent its spread to others should be routine in every
pediatric and adolescent practice. It is important for
clinicians to be prepared to offer prevention counseling,
including abstinence and safe sex as best options for
preventing HIV transmission. Clinicians should be able
to teach all adolescents about correct use of male latex
condoms and emphasize that consistent use is essential
for prevention. Screening all patients ages 13 years and
older for HIV infection identifies asymptomatic patients
unaware of their HIV infection status, providing them
the opportunity to enroll in HIV-specific care for their
own benefit andto reduce the risk of transmitting HIV to
others. HIV-negative adolescents who engage in behav-
iors through which HIV can be transmitted should be
tested at least annually.
Coping With the Diagnosis and PrognosisLearning of a new diagnosis of HIV infection for oneself
or one’s child is emotionally devastating for most people.
While providing a listening ear and emotional support,
clinicians also can offer hope and reassurance about the
availability of effective treatment that can result in im-
proved quality of life and survival for people living with
HIV infection in the United States. Referral to the HIV
infectious diseases HIV infection
Pediatrics in Review Vol.30 No.9 September 2009 345. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
21/71
specialist allows prompt access to specific medical care
and psychosocial supports.
Disclosure of HIV Infection StatusHIV infection remains a stigmatizing diagnosis. Igno-
rance, misinformation, and fear in families and commu-
nities cause people living with HIV infection to keep
their status a secret. However, this practice has negative
consequences, such as isolating the HIV-positive individ-
ual from social support and risking additional spread of
HIV to sexual partners. Planned disclosure to family
members and friends can increase practical and emo-
tional support for the HIV-positive person. Sexual part-
ners can make informed decisions about how to protect
themselves from exposure to HIV.In contrast to adolescents and adults, disclosure of
HIV status to children should be undertaken over time,
providing sequential pieces of practical health informa-
tion that match the developmental capacity of the child.
This process builds a strong foundation for children to
participate meaningfully in their HIV care.
Adherence to Care and TreatmentMost people do not adhere to the treatment recommen-
dations of their health-care practitioners all of the time.
Adolescence is a particularly vulnerable age for nonad-
herence in those who have chronic health conditionssuch as HIV infection. Poor adherence leads to poor
health outcomes in many diseases such as asthma and
diabetes. However, HIV treatment is unique in its re-
quirement for 90% to 100% adherence to drug regimens
to avoid the development of viral resistance and the loss
of future efficacy of anti-HIV drugs. The need for inten-
sive education and support for children and adolescents
living with HIV infection cannot be overstated.
School and Sports ParticipationChildren and adolescents who have HIV infection can
participate fully in the educational and extracurricularactivities in school. There is no obligation to notify
school personnel of a student’s HIV infection status. Any
sport may be played if the student’s health status allows.
For all athletes, regardless of HIV infection status, skin
lesions should be covered properly, and athletic person-
nel should use standard precautions when handling
blood or body fluids that have visible blood. Certain
high-contact sports (such as wrestling and boxing) may
create a situation that favors viral transmission (likely
bleeding plus skin breaks). Some experts advise athletes
who have a detectable viral load to avoid such high-
contact sports.
Transition to Adult Health CareChildren born with HIV infection in the United States
during the 1980s are now young adults. They continue
to be the pioneers who challenge our assumptions and
identify unmet needs for care and support services. No
one anticipated the current need to develop and imple-
ment programs to transition youth successfully to adult
HIV health-care clinicians. Practical concerns such as
transmitting a complete and coherent medical record
and psychological concerns such as the loss of long-term
supportive relationships must be addressed.
Advance Care Planning and Palliative Care Advance care planning is recommended for all who live
with chronic and life-threatening conditions. HIV-infected parents should plan for the care of their depen-
dent children. HIV-infected adolescents and young
adults should designate a person they trust to make
health-care decisions for them if they should become
unable to speak for themselves due to illness or injury.
One approach is to normalize this decision as part of
routine health care when reaching adulthood. This prac-
tice is particularly important for youth who have no
clearly identified next of kin, such as those who are
orphaned and have experienced sequential foster homes.
There continue to be patients who experience dis-
tressing medical complications of HIV infection that, if not reversed, lead to death. Integrating palliative care
with HIV-specific care reduces distress by managing
specific physical and emotional symptoms, encouraging
clear communication, and promoting effective decision-
making. This approach provides the best opportunity to
improve a patient’s quality of life regardless of how long
the patient survives.
Managing Potential HIV ExposureThe pediatrician may be called on to respond to ques-
tions about HIV exposure. Such questions may be about
occupational exposures, such as a needle stick injury to ahealth-care worker, or nonoccupational, such as a child
finding a discarded needle and syringe or an adolescent
who is a victim of sexual assault. The basic approach to
any of these scenarios is to assess the likelihood that
exposure to potentially infectious fluids actually oc-
curred, determine how severe or extensive the exposure
was, and evaluate the likelihood that the fluids are HIV-
contaminated. If the exposure is of high risk and the
source is known to be HIV-infected, postexposure pro-
phylaxis with antiretroviral drugs should begin as soon as
possible after the exposure, but no later than 72 hours.
Guidelines for evaluating risk and recommending post-
infectious diseases HIV infection
346 Pediatrics in Review Vol.30 No.9 September 2009. Provided by Pakistan:AAP Sponsored on September 9, 2009http://pedsinreview.aappublications.orgDownloaded from
http://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.orghttp://http//pedsinreview.aappublications.org
8/9/2019 09-Pediatrics in Review,September2009.PDF(1)
22/71
exposure prophylaxis can be found at http://
aidsinfo.nih.gov.
Having a High Degree of SuspicionIn case study 1, the clinician is presented with a 4-month-
old infant of immigrant African parents whose father died
as a young man with “bad lungs” and whose mother is
breastfeeding exclusively. The clinician’s next steps in-
clude performing a careful history and physical examina-
tion to assess the infant’s growth and development and
to look for conditions suggestive of HIV infection. HIV
antibody testing should be recommended to the mother
for her own health and for planning the care of her baby.
If such testing cannot be arranged promptly, testing theinfant for HIV antibody would indicate the mother’s
HIV infection status. If the mother is HIV antibody-
negative and not engaging in risky behaviors, the infant
does not need additional HIV testing. However, if the
mother is HIV-positive, virologic testing of the infant
with HIV DNA or RNA PCR is indicated throughout
the period of breastfeeding and for 6 months after cessa-
tion. Counseling should be provided about the availabil-
ity of safe and affordable formula feeding and prompt
weaning recommended. Age-appropriate immuniza-
tions should be administered and cotrimoxazole pre-
scribed for PCP prophylaxis until HIV infection isexcluded.
Case study 2 involves a 17-year-old male who has a
rash, fever, and sore throat and recently has traveled to
Georgia, a trip that included a hunting trip. In addition,
the patient reports having sex with both females and
males and no condom use. The scenario leads to consid-
eration of Rocky Mountain spotted fever in the differen-
tial diagnosis. However, it is important to remember that
acute retroviral syndrome in adolescents presents with
fever 96% of the time and both rash and pharyngitis 70%
of the time. Additional signs and symptoms include
lymphadenopathy, myalgia, arthralgia, headache, diar-
rhea, oral ulcers, leucopenia, thrombocytopenia, and
transaminase elevation. In this patient, HIV antibody
testing and HIV RNA testing are indicated as part of
the medical evaluation. Counseling should be pro-
vided to reduce the risk of sexually transmitted infec-
tions.
Conclusion Although it is important to remember that HIV infection
is a multisystem disease requiring regular medical atten-
tion, including health maintenance care, it is equally
important to remember that some of the greatest chal-
lenges young people face have little to do with their
physical illness. Many are in the midst of social complex-
ities that neither they nor their families can begin to
navigate without support. Despite these challenges,
HIV-positive young people are resilient, strong, caring,
appreciative, and worthy of our respect. They are our
teachers, presenting diagnostic, therapeutic, and psycho-
social challenges that open new avenues for clinical in-
vestigation, stimulate our continuous professional devel-
opment, and remind us of our core human values. They
lead the way as we strive to find better ways to manage
their illness and improve the quality of their lives.
Suggested Reading and Useful WebsitesHIV EpidemiologyCenters for Disease Control and Prevention. HIV/AIDS Sur-
veillance Report, 2006 . Vol 18. Atlanta, Ga: United StatesDepartment of Health and Human Services, Centers for Dis-ease Control and Prevention; 2008:1–55. Available at: http:// www.cdc.gov/hiv/topics/surveillance/resources/reports/. Ac-cessed June 2009
HIV Disease Classification1994 revised classification system for human immunodeficiency
virus infection in children less than 13 years of age. MMWR Recomm Rep . 1994;43(RR-12):1–10. Available at: http:// www.cdc.gov/MMWR/preview/MMWRhtml/00032890.htm.
Accessed June 2009
Summary• Mother-to-child transmission of HIV can occur
during pregnancy, labor, delivery, and breastfeeding.Evidence-based interventions (routine screening of pregnant women, initiation of antiretroviral drugsfor mother’s treatment or prevention of MTCT, andavoiding breastfeeding) have reduced transmissionrates in the United States from 25% to 30% to lessthan 2%.
• Triple-drug combination antiretroviral therapyeffectively controls HIV infection and improvessurvival and quality of life for HIV-infected childrenand adolescents. Initial regimens use combinations
of two NRTIs together with an NNRTI or a ritonavir-boosted PI. These regimens have been shown toincrease CD4 counts and achieve virologicsuppression.
• Prevention of serious and opportunistic infectionsreduces morbidity and mortality in children andadolescents who have HIV infection. Recommendationsfor immunizations and chemoprophylaxis vary with the
Recommended