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Course: Pediatric Nursing

Topic: Nursing Care of Child with Immunological Disorders Part I

The Nurses International Community

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Module Goals

Learners will be able to:

Describe anatomy and physiology of immune system in children
List common autoimmune, immune and allergic disorders
Define HIV infection
Describe the stages of HIV infection
Discuss different transmission methods of HIV infection
Identify signs and symptoms of HIV infection
Describe common diagnostic procedures for HIV infection
Describe management of HIV infection in children
Discuss preventive measures for HIV infection
Discuss nursing management of a child with HIV/AIDS

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Immune System

Complex collection of cells and organs that destroys or neutralizes pathogens.

Model of immune function phases:

Barrier defenses (skin and mucous membranes)
Innate immune response (skin, eye cornea, mucus membrane)
Adaptive immune response: White blood cells (leukocytes) known as lymphocytes.

Openstax, 2022

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Parts of Immune System

White blood cells
Antibodies
Complement system
Lymphatic system
Spleen
Bone marrow
Thymus

Better Health, 2017

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Immune System Disorders

Severe combined immunodeficiency (SCID)
HIV / AIDS
Overactive Immune system:

Allergic: (Food allergy, Anaphylaxis)
Asthma, Eczema

Autoimmune Diseases:

Type 1 diabetes
Systemic lupus erythematosus
Rheumatoid arthritis

Better Health, 2017

Nationwide Children’s, 2021

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HIV Infection

HIV (human immunodeficiency virus): virus that attacks the immune system.

Causes Acquired Immunodeficiency Syndrome (AIDS), the most advanced stage of HIV infection.

An estimated 1.8 million children aged 0-14 were living with HIV at the end of 2019, and 150000 children were newly infected.

CDC, 2021

WHO, 2022

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HIV Infection: Stages

Stage 1: Acute HIV Infection

A large amount of HIV in the blood
Very contagious
Some have flu-like symptoms while some may not feel sick

Stage 2: Chronic HIV Infection

Called asymptomatic HIV infection or clinical latency
HIV still active but reproduces at very low levels
May/may not have symptoms
At the end of the phase, (viral load) increases and the CD4 cell count decreases.

CDC, 2021

WHO, 2022

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HIV Infection: Stages

Stage 3: Acquired Immunodeficiency Syndrome (AIDS):

Most severe phase of HIV infection
Has an increasing number of severe illnesses (opportunistic infections)
CD4 cell count drops below 200 cells/mm³
Can have a high viral load and be very infectious
Without treatment, survival rate is about three years

CDC, 2021

WHO, 2022, 2020

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Critical Thinking Question

Which of the following statements are true regarding HIV infection? (Select all that apply)

HIV uses CD4 cells to make more copies of itself
Early identification of HIV infection can help prevent transmission to non-infected people
Early identification of HIV infection does not help in the progression of disease from stage 2 to stage 3 of the infection
CD4 cells count drop below 200 cells/mm³ by stage 2 of the disease

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HIV Infection: Horizontal Transmission

Unprotected sexual contact
Body fluids (vaginal and cervical, semen and blood)
Intravenous drug abusers (syringes and needles soiled with HIV-infected blood)
HIV-contaminated needles or blades in traditional rituals (e.g. circumcision)
Accidental needle-stick injuries
A blood transfusion with HIV-infected blood

CDC, 2022

Bettercare, 2020a

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HIV Infection: Vertical Transmission

95% of HIV-infected children are infected by their mother
Transmitted from a mother to baby during:

Pregnancy
Birth, or Delivery
Breastfeeding

Wet-nursing (feeding another woman’s infant) with HIV-contaminated breast milk

CDC, 2022

Bettercare, 2020a

Contact info: info@nursesinternational.org

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HIV Infection: Risk Transmission (Pregnancy)

Increase the risk of transmission to fetus if the mother:

Becomes infected with HIV during pregnancy
Has advanced HIV infection (stage 3)
Has a CD4 count below 350 cells/μl
Has a detectable viral load above 400 copies/ml

Other factors:

Chorioamnionitis (Placental membranes infection)
Malaria
Amniocentesis
Maternal undernutrition, including vitamin A deficiency

Bettercare, 2020a

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HIV Infection: Risk Transmission (Birth)

Risk to infant during labour and deliver: (any time there is potential for contamination via blood)

Preterm labour
Prolonged labour and prolonged rupture of the membranes (more than four hours)
Episiotomy
Instrument delivery (forceps or vacuum)
Use of a scalp clip or fetal scalp pH monitoring
Birth order (common in first-born than second-born twins)

Elective Caesarean section reduce the risk of HIV

Bettercare, 2020a

Contact info: info@nursesinternational.org

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HIV Infection: Risk Transmission (Breastfeeding)

With mixed breastfeeding for 24 months:

Risk of transmission is about 15% (if no antiretroviral prophylaxis)
5% during the first six months, 5% second six months and an additional 5% during the second year

With exclusive breastfeeding:

Risk of transmission is much less (if mother on antiretroviral treatment or the infant on prophylaxis)

With exclusive formula feeding: No risk of transmission

Bettercare, 2020a

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Critical Thinking Question

Which of the following pose a risk of HIV transmission to infants and children? (Select all that apply)

Unprotected sexual intercourse with multiple partners
Intravenous drug use with infected blood
Cesarean section before onset of labor of HIV infected mother
Exclusive formula feeding by infected mother
Breastfeeding by infected mother

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HIV Infection: Overall Risk Transmission

The overall risk of mother to child transmission is 35% if steps are not taken to reduce the risk

Example:

5% in pregnancy plus 15% at delivery plus 15% with mixed breastfeeding

Bettercare, 2020a

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HIV Infection: Common Clinical Presentation

Weight loss or failure to thrive
Persistent oral thrush beyond first two months of life
Enlarged lymph nodes, liver, spleen or parotid glands
Severe rash
Repeated pneumonia
Severe forms of oral herpes
Chronic diarrhoea
Tuberculosis
Delayed developmental milestones

Bettercare, 2020b

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HIV Infection: Diagnosis

For < 18 months of age:

Viral tests (HIV DNA PCR test)
HIV viral load (referred to as HIV RNA PCR test)
HIV infection is confirmed when two consecutive HIV DNA PCR tests are positive

For 18 months or more:

Antibody tests: HIV rapid and HIV ELISA tests
HIV infection is confirmed when two consecutive HIV rapid tests are positive

Bettercare, 2020b

Contact info: info@nursesinternational.org

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HIV Infection: Diagnosis

Window Periods:

The time after infection with HIV when the blood tests may still be negative

For viral tests: Ranges from 3 days to 6 weeks
For antibody tests e.g. HIV ELISA: Ranges between 2 weeks and 12 week

During the first six weeks after infection the tests may be negative even if the child is infected with HIV.

Bettercare, 2020b

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HIV Infection: Diagnosis (Immunology)

CD4 cells number measures the degree of damage to the immune system (risk of infections)
In normal healthy adult (HIV-negative):
CD4 count: above 500 cells/µl
Normal children: 25% or more CD4
CD4 percentage:

15 to 24 indicates moderate immune suppression
Less than 15 indicates severe immune suppression

Bettercare, 2020b

Contact info: info@nursesinternational.org

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Case Study

A woman with asymptomatic HIV infection delivers a preterm infant who is clinically healthy. She wants to know whether her infant is also infected with HIV. The mother has a normal CD4 count.

Can a rapid test be used to determine whether this infant is infected with HIV?

Yes
b. No

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HIV Infection: Management

Cotrimoxazole prophylaxis
Monitor and support growth, neurodevelopment and nutrition
Monitor clinical and immunological staging
Diagnose and manage HIV-associated infections
Provide counselling and support
Provide and monitor antiretroviral treatment when indicated
Access to social grants and other supportive options
Young children with HIV infection should be informed of their condition when they are old enough to understand and emotionally handle the information
Conduct home visits as needed

Better care, 2020b

Contact info: info@nursesinternational.org

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HIV Infection: Immunization

Safe to give most routine immunization to well HIV-exposed infants in the first months of life.
Countries have differing requirements and the recommended therapy continues to evolve.
Consultation with infectious disease and Immunologist is advised to evaluate the severity of the disease.
See recommendations at link below:

Bettercare, 2020b

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HIV Infection: Antiretroviral Therapy

Also known as HAART (highly active antiretroviral treatment)
Prevent HIV from multiplying in CD4 lymphocytes
There are four main classes:

‘Nucs’
‘Non-nucs’
‘PIs’
Integrase inhibitors (‘IIs’)

Better care, 2020b

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HIV Infection: Prevention (Mother to Child)

The important strategies:

Antiretroviral (ARV) drugs for HIV-infected mothers and their infants.
Elective caesarean section for HIV-infected women who reach term without achieving plasma HIV virologic suppression.
Replacement feeding instead of breast milk to infants of HIV-infected mothers.

Siberry, 2014

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Management of HIV Positive Pregnant Women:

Labour and Delivery

HIV-positive women need not be isolated during labor; however, privacy during counselling needs to be maintained

Avoid unless clinically essential:

Artificial rupture of membranes
Episiotomy
Attaching scalp electrode placement
Vacuum extraction

Forceps may be used with caution

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WHO recommends that all mothers living with HIV should receive lifelong antiretroviral therapy (ART) to support their health and to ensure the wellbeing of their infants

For Resource limited settings:

There are both dangers and advantages to women living with HIV breastfeeding. The advantages of breastfeeding are the lower risk of gastroenteritis, pneumonia and undernutrition, especially in poor communities. The risk of the infant dying due to these conditions is greater than the small risk of the infant becoming HIV infected. Therefore, many mothers living with HIV from poor communities should be advised to exclusively breastfeed their infants for 6 months followed by extended breastfeeding after introducing solid foods

2. Is mixed feeding better than no breastfeeding at all, if the mother is on HIV treatment?

Yes. Mothers living with HIV can be reassured that ART reduces the risk of post-natal HIV transmission even when the baby is on mixed feeding. Although exclusive breastfeeding is recommended for the first 6 months, mixed feeding is better than no breastfeeding. Encouraging mothers living with HIV to breastfeed exclusively is still strongly advised because it benefits the infant in many ways including, reduced illness, and improved growth and development.

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HIV Infection: Prevention (Breast feeding)

USA: The best way to prevent transmission of HIV to an infant through breast milk is to not breastfeed.

Infant formula and pasteurized donor human milk are safe.

In resource-limited settings:

WHO: breastfeed exclusively for the first 6 months of life and continue breastfeeding for at least 12 months, with the addition of complementary foods.

CDC, 2022

Contact info: info@nursesinternational.org

WHO recommends that all mothers living with HIV should receive lifelong antiretroviral therapy (ART) to support their health and to ensure the wellbeing of their infants

For Resource limited settings:

There are both dangers and advantages to women living with HIV breastfeeding. The advantages of breastfeeding are the lower risk of gastroenteritis, pneumonia and undernutrition, especially in poor communities. The risk of the infant dying due to these conditions is greater than the small risk of the infant becoming HIV infected. Therefore, many mothers living with HIV from poor communities should be advised to exclusively breastfeed their infants for 6 months followed by extended breastfeeding after introducing solid foods

2. Is mixed feeding better than no breastfeeding at all, if the mother is on HIV treatment?

Yes. Mothers living with HIV can be reassured that ART reduces the risk of post-natal HIV transmission even when the baby is on mixed feeding. Although exclusive breastfeeding is recommended for the first 6 months, mixed feeding is better than no breastfeeding. Encouraging mothers living with HIV to breastfeed exclusively is still strongly advised because it benefits the infant in many ways including, reduced illness, and improved growth and development.

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HIV Infection: Nurses Role

Daily Routine care
Preventive measures for opportunistic infections
Health education to high risk mother ( immunization, breast feeding, self care)
Monitor and support growth,neurodevelopment and nutrition
Provide counselling and support
Provide and monitor antiretroviral treatment when indicated

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

An HIV-infected woman asked the nurse how she should tell her young son that he also has HIV infection. He is starting to show the first signs of puberty. What would be nurse’s appropriate response? (Select all that apply)

“Inform your son as soon as possible so he will prevent unsafe sexual intercourse with others.”
“First we should ensure that your child is mature enough to understand what it means and able to emotionally handle the information.”
“We must ensure that your son gets sex eduation.”
“Do you want the doctor to inform your son?”

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Red Flags

A child with HIV infection who has low CD4 count cell.

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References:

Better Health. (2017). Immune System Explained. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/immune-system

Bettercare. (2020a). Bettercare Learning Programmes/Childhood HIV/1. Introduction to childhood HIV infection. https://bettercare.co.za/learn/childhood-hiv/text/01.html

Bettercare. (2020b). Bettercare Learning Programmes/Childhood HIV/2. Clinical and immunological diagnosis of HIV infection. https://bettercare.co.za/learn/childhood-hiv/text/02.html

Bettercare. (2020c). Bettercare Learning Programmes/Childhood HIV/ 3. Management of children with HIV infection. https://bettercare.co.za/learn/childhood-hiv/text/03.html#case-study-4

CDC. (2021 June 1). About HIV. https://www.cdc.gov/hiv/basics/whatishiv.html

CDC (2022 March 4). Ways HIV Can Be Transmitted. https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html

Contact info: info@nursesinternational.org

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References:

CDC. (2022 March 2). Breast Feeding: Human Immunodeficiency Virus (HIV). https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hiv.html#:~:text=In%20the%20United%20States%2C%20to,body%20fluids%2C%20including%20breast%20milk.

Nationwide Children's. (2021). Immune System Disorders. https://www.nationwidechildrens.org/family-resources-education/family-resources-library/immune-system-disorders

Openstax. (2022). Anatomy of the Lymphatic and Immune Systems. Anatomy and Physiology. https://openstax.org/books/anatomy-and-physiology-2e/pages/21-1-anatomy-of-the-lymphatic-and-immune-systems

Siberry G. K. (2014). Preventing and managing HIV infection in infants, children, and adolescents in the United States. Pediatrics in review, 35(7), 268–286. https://doi.org/10.1542/pir.35-7-268

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