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Infant born to mother with HIV

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Dr. Amna Nazar

MBBS, FCPS (Paeds)

Clinical Fellow in Neonatology

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scenario

  • A 30-year-old woman is diagnosed with HIV during labor at 39 weeks of gestation. She has not received antiretroviral therapy (ART) during pregnancy and presents in active labor. She delivers a male infant via vaginal delivery. The infant has an Apgar score of 8 at 1 minute and 9 at 5 minutes and shows no immediate signs of distress.
  • Delivery mode
  • When to start prophylaxis
  • Feeding breast milk or formula

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Data source: UNAIDS 2018 estimates.

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Risk of Vertical HIV Transmission

Factors

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Risk of Transmission (No Intervention)

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Risk with Optimal Intervention

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Key Interventions

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In utero

High maternal Viral Load

Low CD4 count

High risk (25-40%)

Significantly reduced with mat. ART

Antiretroviral Therapy (ART) for mother

Regular monitoring

Timing of Infection

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Higher risk if acquired during pregnancy especially 3rd trimester and

breastfeeding

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Mat ART initiation as soon as possible

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Early HIV testing for pregnant women

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Intrapartum factors

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  • High risk (50%) with
  • SVD ( VL>1000)
  • Instrumentation
  • PROM >4Hrs

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  • Reduced with ART
  • C-section
  • Avoid instrumentation

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ART during labor, consider C-section for high VL

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Infant Feeding

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Risk through breastfeeding

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  • Formula feeding or
  • Reduced with ART & exclusive breastfeeding

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Informed decision on infant feeding method

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Labour room management

  • Standard precautions
    • Gloves, Hand hygiene
    • Mask, Apron
    • Careful handling of blood-stained sharps

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  • Baby cleansing/bath
  • Shift to NICU/intermediate care

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Resource limited settings�Mother known HIV on ART� ( start within 6-12Hrs of life)

In last 4wks gestation

Maternal Viral load (VL)

Mother on ART

Time of Mat. diagnosis

Treatment of baby

Breast feeding

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Formula / Replacement feeding

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High risk infants

>1000/mL

<4wks

Or no treatment

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Within 72Hrs of delivery

Zidovudine +

Nevirapine

for 12 weeks

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Zidovudine +

Nevirapine

for 6 weeks

Low risk infants

<1000/mL

>4wks

Previously diagnosed

Nevirapine 🡪 6wks

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Zidovudine

OR

Nevirapine

🡪4wks

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Dosing of ART prophylaxis

Infant age

Nevirapine

Zidovudine

�Birth weight 2000 to 2499 grams*

10 mg once daily�(1 mL of syrup once daily)

10 mg twice daily�(1 mL of syrup twice daily)

Birth weight ≥2500 grams

15 mg once daily�(1.5 mL of syrup once daily)

15 mg twice daily�(1.5 mL of syrup twice daily)

>6 weeks to 12 weeks

 

20 mg once daily�(2 mL of syrup once daily or half a 50 mg tablet once daily)

60 mg twice daily�(6 mL of syrup twice daily or a 60 mg tablet twice daily)

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Specific Side Effects Related to ART Prophylaxis and monitoring �

Zidovudine (AZT)

Anemia, neutropenia, gastrointestinal discomfort.

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Complete blood counts (CBC)

Lamivudine (3TC)

Generally well-tolerated; rare cases of pancreatitis.

Monitor for signs of pancreatitis and liver function tests (LFTs).

Nevirapine (NVP)

Rash, hepatotoxicity.

Frequent LFTs to detect liver toxicity and observe for skin reactions.

General Signs to Watch For:

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  • Changes in behavior
  • Feeding problems:
  • Skin changes
  • Breathing difficulties
  • Abdominal issues
  • Fever

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Virologic testing for infants�NATS ( HIV DNA &RNA assay ).. Don’t use cord blood

High risk formula fed infants

Low risk formula fed infants station)

(sustained viral suppression after 20 wks gestation)

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Infants who are breast fed by HIV +mother

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  • Birth

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  • 14-21days

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  • 1-2 monthly testing till 6months

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  • birth( suggested but not required)

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  • 14-21 days

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  • 1-2 months

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  • 4-6 months

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  • Birth

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  • 14-21 days

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  • 1-2 monthly testing till 6months

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  • Every 3 months through out breast feeding and 6 months after cessation

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Other postnatal management

  • Pneumocystis prophylaxis – at 2 months in selected cases
  • Check for CMV
      • Congenital CMV –21st DOL .. Urine and saliva PCR

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  • Vaccinations
    • Hep B
    • BCG
      • HIV-exposed, status unknown: Vaccinate in TB-endemic areas.
      • HIV-negative: Vaccinate.
      • HIV-positive: Contraindicated.

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Key message

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  • Overall Risk of HIV in child = 15-45%
  • Can be reduced to <2% (can be <0.5%) with Comprehensive maternal & infant care

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References

  1. Transforming Vision into Reality: The 2024 Global Alliance Progress Report on Ending AIDS in Children by 2030 (unaids.org). Geneva: Joint United Nations Programme on HIV/AIDS; 2024. https://www.unaids.org/sites/default/files/media_asset/transforming-vision-into-reality_en.pdf (Accessed on August 12, 2024).
  2. Joint United Nations Programme on HIV/AIDS (UNAIDS). The path that ends AIDS: 2023 UNAIDS global AIDS update. https://thepath.unaids.org/wp-content/themes/unaids2023/assets/files/2023_report.pdf (Accessed on June 20, 2024).
  3. John GC, Kreiss J. Mother-to-child transmission of human immunodeficiency virus type 1. Epidemiol Rev 1996; 18:149.
  4. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994; 331:1173.

5-Shaffer N, Chuachoowong R, Mock PA, et al. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok Collaborative Perinatal HIV Transmission Study Group. Lancet 1999; 353:773.

6-Clarke DF, Penazzato M, Capparelli E, Cressey TR, Siberry G, Sugandhi N, Mirochnick M. Prevention and treatment of HIV infection in neonates: evidence base for existing WHO dosing recommendations and implementation considerations. Expert review of clinical pharmacology. 2018 Jan 2;11(1):83-93.

7-Technau KG, Kuhn L, Coovadia A, Carmona S, Sherman G. Improving early identification of HIV‐infected neonates with birth PCR testing in a large urban hospital in Johannesburg, South Africa: successes and challenges. Journal of the International AIDS Society. 2017;20(1):21436.

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COVID19 IN NEWBORN�

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Scenario

  • A 28-year-old woman with COVID-19 (PCR-positive, confirmed two days prior to delivery) presents in active labor at 38 weeks of gestation. She has mild symptoms, including fever (38.5°C), fatigue, and a cough. Her oxygen saturation on room air is 95%. The baby is born via spontaneous vaginal delivery without complications, has an Apgar score of 8 at 1 minute and 9 at 5 minutes, and shows no immediate signs of respiratory distress or illness.

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Qs

  • Recommended method of feeding ?
  • Recommended isolation protocol for a neonate
  • Investigations for neonate
  • Role of steroids , antiviral in this pt

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Transmission

  • Primary transmission----- respiratory droplet

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  • Vertical transmission ----rare

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  • Testing neonates born to mothers with COVID-19 is essential.

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SYMPTOMS IN NEONATES �

  • Neonates –
    • Fever – 64 percent
    • Feeding intolerance – 26 percent
    • Cough – 22 percent
      • Tachypnea – 19%
      • Diarrhea – 8 percent
      • Rhinorrhea – 8 percent
      • Somnolence/irritability – 7 percent
      • Rash – 2 percent
  • Preterm infant:
    • Hyplglycemia
    • Bone marrow supression

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Mother Confirmed or Suspected COVID 9

Labour Room management

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  • Contact and droplet precautions
  • Resuscitate as per NRP
  • Isolation in incubator in Neonatal Unit
  • Send samples for covid19

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Breast Feeding Guidelines

  • Encourage with Precautions— no evidence of transmission

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  • Precautionary Measures for Mothers:
    • Wear a mask while breastfeeding.
    • Hand hygiene
    • Sanitize breast pump equipment after use.

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Asymptomatic baby ---- well mother

  • Room in with mother in isolation
  • Continue precautions
  • Encourage breast feeding---mother with mask, hand hygiene

Mother Covid 19 Negative

Discontinue isolation

Supportive care

Mother Covid PCR +ve & Baby +/-

Send baby sample for PCR

Continue isolation with mother with precautions and supportive care

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Well baby – Sick mother

  • Shift baby to Neonatal Unit
  • Isolate in incubator
  • Monitoring and Supportive care

Mother Covid PCR +ve

Send baby samples for covid PCR

Baby PCR –ve

Remove from Incubator

Repeat PCR after 48hrs

Supportive care

Baby PCR +

Continue isolation

Supportive care

Repeat PCR every 2 days till

2 samples–ve 48hrs apart - discontinue isolation

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Symptomatic Neonate

  • MILD CASES
    • Supportive care:
      • Hydration and feeding.
      • Monitoring oxygen levels and vital signs.

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  • MODERATE TO SEVERE CASES
    • Admit in NICU
      • Respiratory support(Invasive /Non-invasive .)
    • Antiviral therapy ( Remdesivir)
      • Limited evidence of routine use
    • Corticosteroids:
      • May be used in severe disease
    • IVIGS
      • limited use
    • Supportive care as above.

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Multisystem Inflammatory Syndrome (MIS-C)

  • MIS-C in neonates is rare, but cases have been reported.
  • Presentation
    • Fever, Hypotension, Shock , Cardiac dysfunction ,Gastrointestinal and Dermatologic findings
  • Diagnosis
    • Clinical criteria + laboratory evidence of inflammation + Maternal/Neonatal PCR +ve
  • Management:
    • Intensive care
    • Immunomodulatory therapies (IVIG, corticosteroids)
    • Supportive care for organ dysfunction

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References

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  • 1-Singh, Shalendra; Patnaik, Subhasish1; Hota, Rabi Narayan2; Ambooken, George Cherian; Krishna, Venigalla Sri. COVID-19 and Pregnancy: Challenges for an Anesthesiologist. Archives of Medicine and Health Sciences 9(1):p 107-112, Jan–Jun 2021. | DOI: 10.4103/amhs.amhs_38_21
  • 2-LEMMA K, DABA M. Staffing, personnel, and resources. COVID-19. 2020 May 6:51.
  • 3- Coronavirus (COVID-19) infection and pregnancy [Internet]. Royal College of Obstetricians & Gynecologists. [cited 2020Apr3]. Available from: https://www.rcog.org.uk/coronavirus-pregnancy
  • 4-. Queensland Clinical Guidelines Perinatal care of suspected or confirmed COVID-19 pregnant women. Guideline No. MN20.63-V1-R25. Queensland Health. 2020. Available from: http://www.health.qld.gov.au/qcg
  • 5-. Pediatric COVID-19 Guidelines-Version 1.0, March 2020-Aga Khan University hospital
  • 6-Briana, Despina MD, PhD; Syridou, Garyffalia MD; Papaevangelou, Vassiliki MD, PhD. Perinatal COVID-19. The Pediatric Infectious Disease Journal 40(12):p e504-e506, December 2021. | DOI: 10.1097/INF.0000000000003356
  • 7-Vardhelli V, Pandita A, Pillai A, Badatya SK. Perinatal COVID-19: review of current evidence and practical approach towards prevention and management. European journal of pediatrics. 2021 Apr;180:1009-31.
  • 8- Sankaran D, Nakra N, Cheema R, Blumberg D, Lakshminrusimha S. Perinatal SARS-CoV-2 infection and neonatal COVID-19: a 2021 update. Neoreviews. 2021 May 1;22(5):e284-95.

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Neonatal Dengue Infection

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When to suspect dengue in neonate

Newborn with fever, rash , thrombocytopenia

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AND

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    • Dengue epidemic
    • Unexplained peripartum fever
    • Maternal dengue fever 10 days before or after delivery
    • Neonate with culture –ve sepsis in endemic areas

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Vertical Transmission

  • Intrauterine transmission is greatest

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    • When a pregnant woman delivers at or near the peak of viremia.
    • Dengue in late pregnancy (Insufficient anti DENV IgG to transfer)
    • Maternal age <20 yrs -- high circulating antidengue antibodies

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  • Possible in all three trimester
      • 1st trimester 3.8%
      • 2nd trimester 7.7%
      • 3rd trimester 77%
      • Immediate postpartum period 11.5%

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Perinatal infection

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  • Average time maternal fever to neonatal symptoms -- 7 days (5-13).
  • Mode of delivery does not affect the rate of transmission.
  • Breastfeeding may contribute.
  • Severe viremia/fever in mother – severe neonatal infection.

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Neonatal Presentation

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  • Fever and Thrombocytopenia
    • Appears 1-11 days after birth
      • Average 4 days
    • Lasts 1-5 days.
  • Hepatomegaly, Hemorrhage, Effusion, and Rash.
  • Dengue shock syndrome
    • Rare
    • severe bleeding requiring platelet and red blood cell transfusions.

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Congenital Infection

  • Neurological Abnormalities
    • Anencephaly, microcephaly, Encephalocele, Hydrocephalus

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  • Stillbirth - 5.0%,
  • Preterm birth - 20%
  • Low birth weight - 5.0%

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Mortality

  • The mortality rate for severe dengue fever is 0.8–2.5%.

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Diagnosis

  • Dengue NS1 antigen detection
  • Viral detection (RT-PCR) in infant blood or cord blood
  • Serology
    • The positive dengue serology together with maternal dengue infection during pregnancy.
      • Negative serology on Day1 may be due to low viremia at that time.
    • Immunoglobulin (Ig)M (4 days after the onset of illness).
      • Acute infection -> 4 times rise in antibody titre.

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Management

Supportive care is crucial:

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  • Fluid management
  • Monitoring for and management of bleeding
  • Respiratory support
  • Management of shock
  • Prompt recognition and intensive monitoring

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References

1-Gupta S, Choudhury V, Gupta NP, Gupta V, Pandita A. Congenital dengue in neonate. Clinical Case Reports. 2020 Dec 4;9(2):704.

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2-Yadav B, Gupta N, Gadepalli R, Nag VL. Neonatal dengue: an under-diagnosed entity. BMJ Case Reports CP. 2021 Aug 1;14(8):e241727.

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3-Thomas J, Thomas P, Reeba George C. Neonatal dengue. Int J Contemp Pediatr [Internet]. 2017 Oct. 24 [cited 2025 Apr. 23];4(6):2234-6. Available from: https://www.ijpediatrics.com/index.php/ijcp/article/view/1139

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4-Nguyen TM, Huan VT, Reda A, Morsy S, Giang HT, Tri VD, Mau NK, Elfaituri MK, Hieu TH, Hung NT, Hirayama K. Clinical features and outcomes of neonatal dengue at the Children’s Hospital 1, Ho Chi Minh, Vietnam. Journal of Clinical Virology. 2021 May 1;138:104758.

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5-thomas jessy. Neonatal dengue. International Journal of Contemporary Pediatrics. 2017;

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6-Singh S, Alallah J, Amrit A, et al. Neurological Manifestations of Perinatal Dengue. Newborn 2023;2(2):158–172.

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7-Shabbir S, Ehsan S. Congenital Dengue Infection: A Novel Case of vertical transmission of Dengue virus in Karachi, Pakistan. Pakistan Journal of Medicine and Dentistry. 2021;10(3):98-101.

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MCQ

A neonate presents with fever and low platelets. The mother had dengue three days before giving birth. Which statement BEST evaluates the situation?

  • a) Maternal dengue timing rules out neonatal dengue.
  • b) Neonatal dengue is likely; monitor and support.
  • c) Bacterial sepsis is more probable; start antibiotics.
  • d) Petechiae confirms dengue; focus on virus confirmation.

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