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NICU guideline identifier

HIV - management of infants born to HIV+ pregnant women

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Prenatal period

A paediatric consultant (usually Dr Rowley) should aim to see the parent and discuss the postnatal management of the infant with her. A High Risk obstetrician and Obstetric Physician will usually monitor the pregnancy.

A copy of this guideline should be placed in the mother's notes for reference during the pregnancy and labour/delivery.

Maternal blood specimen should be taken for HIV PCR prior to zidovudine being commenced. If not an established patient here, send to be processed by Auckland City Hospital Department of Virology and Immunology, LabPlus, Building 31, Auckland Hospital (3x EDTA tubes). This will confirm that the mother's virus is detectable by PCR in the Auckland system.

Confirm that zidovudine syrup is available at the Auckland City Hospital Pharmacy. This will ensure availability if there is premature delivery. Liaise with paediatric pharmacist 93- 4136.

Obtain details of maternal antiretroviral treatment during pregnancy and current HIV viral load prior to delivery.

Post delivery

Vitamin K should be given intramuscularly once the baby has been bathed.

Call the paediatric registrar to review the baby and to prescribe the antiretroviral therapy while the baby is still on Labour and Birthing Suite - This is required to ensure that the first antiretroviral dose is given within 4 hours of birth.

Zidovudine oral liquid is stocked on NICU and labour and Birthing suite

Breastfeeding is contraindicated (as there is an increased risk of HIV transmission to babies, and an alternative - that is, infant formula - is available).

The number of paediatric staff involved in the care of the baby should be kept to a minimum.

Strict confidentiality as is usual must be maintained, especially when there are visitors in the room.

Testing

Time  Tests  FBC Clinical Review
T Cell Subsets PCR HIV Antibody
(Western Blot)
 Day 1
(Cord blood) 
No longer required from cord blood    +
(Pre-treatment) 
+
Week 1    + +  + +
Week 4-8      +
(Post-treatment) 
4-6 months     
12 months  +    
18 months
(if still seropositive at 12 months) 
   
  • Any positive PCR test must be confirmed by repeat test to confirm infection.
  • Repeat HIV PCR and antibody testing after 18months is necessary until the serology is negative.
  • If there is concern regarding confidentiality, it is optional to use a code for all lab forms: 4 letter, 6 number code - first 2 letters of the last name, first letter of the Christian

Treatment

Antiretrovirals

Possible additions to therapy following discussion between the neonatologist and paediatric ID team are -

  • Nevirapine if indicated 2mg/kg, single dose to be given ASAP within 3 days of birth. As this is non formulary - contact the pharmacist in advance to arrange a supply.
  • Lamivudine (3TC, 10mg/ml) 2mg/kg/dose twice-daily to start within 8 hours of delivery. As this is non formulary - contact the pharmacist in advance to arrange a supply.

Prophylaxis

If the initial PCR is positive or if the mother has an unsuppressed viral load at delivery, start Co-Trimoxazole 0.5mls/kg, daily at 6 weeks. Stop when testing at 4 months confirms absence of HIV infection.

Immunisations

No BCG vaccination should be given until it is clear that the infant is HIV negative at the final test performed at 12-18 months. If there is extremely high TB risk (eg. mother on active treatment) discuss with ID team regarding earlier BCG immunisation. 

  • Inform the parents that their baby should not receive BCG vaccination so that they can inform community health workers who may offer immunisation prior to the infant's negative status being confirmed.
  • Include this information in the discharge letter to avoid inadvertent BCG immunisation.
  • Alert Public Health Medicine Specialists that this infant is eligible to receive BCG vaccination but BCG needs to be deferred until negative HIV results have been obtained at 12-18 months of age. Email address bcg@adhb.govt.nz
  • At the 15-18 month final check the neonatologist will advise parents that the infant may be eligible for BCG vaccination and direct them to the Auckland region Public Health Service website (http://www.arphs.health.nz/) where they can fill in an online form for BCG eligibility and appointment. Alternatively the neonatologist may also with the parents' permission copy the letter clearing the infant for live vaccines to Dr Lavinia Perumal , Medical Officer of Health, ADHB LaviniaP@adhb.govt.nz  and they can contact the parents directly to arrange an appointment

All other immunisations should be given on time.

People to be contacted

Neonatologists - Dr Simon Rowley (or in his absence, the on-call Level 2 specialist) should be contacted during normal working hours.

  • If the baby is born overnight, the on-duty registrar or NS-ANP should be contacted immediately after delivery and should notify Dr Rowley (or the on-call specialist) at the first available opportunity.
  • Paediatric Infectious Disease Team (Dr L Voss, through ADHB operator). Phone as well as written consultation form should be sent.

Virologist - Dr K Croxson, Department of Virology and Immunology, LabPlus Building 31, Auckland Hospital, ext 6130, loc 93-4197, should be informed that the bloods are being sent.

Follow up

Dr Rowley will follow these babies at the Neonatal Outpatient Clinic until 18 months, unless they are infected when care will be transferred to Dr L Voss, Starship Children's Hospital.

ALL babies require a discharge letter to the GP, copied to Dr Rowley, Dr L Voss and parents.

Arranging discharge medication

As a rule anti-retroviral therapy for discharge is not supplied by the ward. Discharge planning for antiretroviral oral liquids will require application for Special Authority with endorsement from an approved antiretroviral prescriber (S.Rowley, L.Voss, E.Best)

On the assumption that the Special Authority will be approved the outpatient supplies should be obtained by the clinician from a community pharmacy eg. Level 5 Pharmacy Auckland City Hospital or Grafton Pharmacy, and handed to the mother, along with some oral syringes prior to discharge.

Notify the ward pharmacist of any pending discharge patient and ensure the mother/caregiver has been instructed in administration and is competent.

Nursing care of baby whose mother is HIV positive

  1. Use standard precautions.
  2. Babies greater than 32 weeks gestation if condition stable, after birth should be bathed as soon as possible using standard baby wash
    - A nurse should wear a long sleeve gown and gloves whilst carrying out the bath
    - Where possible include either parent in the bathing activity, however this should not delay the timing of the bath.
  3. After baby is bathed Vitamin K is given IM in right leg (Parent consent needed).
  4. Baby is not given breast milk or breastfed (as there is increased risk of HIV transmission to baby).
    - When gestationally appropriate, teach parents how to prepare and give a bottle feed to baby (see bottle feeding guideline).
    - Ask parents to provide bottle and teat that they will use at home.
    - Document feeding plan on observation chart.
  5. Ensure baseline FBC is taken.
  6. Commence antiretroviral medication within 4hrs (see Zidovudine guideline)
    - Liaise with ward pharmacists to arrange supply of discharge medication
    - Educate parents how to administer the oral liquid; discuss the bottle label instructions with them.
  7. No BCG vaccination or other live vaccines should be given until baby's status is clear.

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Document Control

  • Date last published: 08 August 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years