Infant Diagnosis Case Studies 2

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Infant Diagnosis Case Studies - 2

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Case 1 Ayana

• Ayana is an HIV-exposed 6 week old baby girl who
  has come for her intake visit
• Her mother was not eligible for HAART during the
  pregnancy and took sdNVP intrapartum with
  AZT/3TC for 7 days postpartum
• Birth History
• Weight- 3 kg
• Child received SD-NVP
• Baby has been exclusively breastfed
• Physical Exam
• Length 53 cm Weight 4.4 kg Head
  circumference- 38.5 cm
• Development-She has good head control
• Oral thrush

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Ayanas Growth Chart
Weight Birth- 3 kg 6 wks -4.4 kg
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Case 1 Ayana

• What should be done at this visit?

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Case 1 Ayana

• Normal exam and good growth
• Nystatin Suspension for thrush
• Cotrimoxazole Prophylaxis is started
• Routine vaccines are given
• DBS DNA PCR is sent
• Counseling on exclusive breastfeeding occurs
• Follow-Up is scheduled for 1 month

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Case 1 Ayana

• Ayana returns at 10 weeks
• She continues to breastfeed, and is gaining
  weight
• The thrush has cleared and she is tolerating the
  cotrimoxazole
• Her DNA PCR test is negative

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Case 1 Ayana

• Her mother asks if she should stop breastfeeding
  since the test is negative
• What will you tell her?

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Case 1 Ayana

• You explain the benefits of breastfeeding to her
  mother
• You tell her of the risks associated with early
  weaning (diarrheal diseases, malnutrition and
  pneumonia)
• You tell her that the benefits of exclusive
  breastfeeding outweigh the risk associated with
  HIV transmission
• You encourage her to continue breastfeeding until
  six months at which time she can start
  complementary foods
• You refill the CTX prescription, encourage her to
  continue breastfeeding
• You encourage mother to go back to the CTC for
  follow up and repeat CD4 since she is not
  currently on ART

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Case 1 Ayana

• Ayana returns for her vaccine visits
• She is well, has gained weight and is taking
  cotrimoxazole appropriately
• At her 6 month visit, her mother tells you she
  stopped breastfeeding 3 weeks ago when she was
  started on ART because her CD4 had fallen to 180
  
• She was told by the provider that ARVs are found
  in breast milk so she decided to stop
  breastfeeding

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Case 1 Ayana

• She notices the expression on your face and ask
  why
• You explain to her that she could still
  breastfeed even while taking ARVs
• Ayana is still taking cotrimoxazole
• Her mother is anxious to know if she can stop
  giving the medication since Ayana is doing very
  well

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Case 1 Ayana

• Ayanas mother asks if she should start
  breastfeeding again?
• What will you tell the mother?
• When can she giving Ayana CTX?
• When should Ayana have her next test?

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Case 1 Ayana

• You explain to Ayanas mother that once she has
  weaned her it is more dangerous to restart
  breastfeeding
• You advise her on how to prepare nutritious food
  for Ayana
• You tell her Ayana needs close follow-up since
  the weaning period is a period of great
  vulnerability for all children
• You advise her to continue cotrimoxazole for
  Ayana until you have definitely excluded HIV
  infection

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Case 1 Ayana

• You will test her again at least 6 weeks after
  she stopped breastfeeding
• You refill her cotrimoxazole and schedule follow
  up in 2 months
• You advise her to come back to the clinic if
  Ayana should fall sick before then

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Case 1 Ayana

• What test will you do when she comes back to
  clinic?

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Case 1 Ayana

• Ayana is 9 months old when she comes back for HIV
  testing
• You choose to do a rapid antibody test and the
  result is negative
• You tell mom that the baby does not have HIV.
  You discontinue cotrimoxazole and tell her no
  more testing is necessary
• You discharge her from the program and tell her
  she needs to continue follow-up in the MCH clinic

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Case 2 Hakeem

• Hakeem is a 5 month old male who presents for his
  check up
• He has been followed in the clinic since 6 weeks
  of age
• His first DNA PCR at 6 weeks was negative
• He is breastfeeding at night, but is fed porridge
  and water during the day by Grandma who does not
  know of moms status since mom started working
  one month ago
• Lately, Hakeem has been feeding poorly and has
  had diarrhea for the past 6 days

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Case 2 Hakeem

• Hakeem receives cotrimoxazole, but sometimes he
  misses a dose when Grandma is caring for him,
  since she does not know that he needs this
  medicine
• Today he weighs 5.8kg
• Physical exam is significant for
• Mild dehydration
• Diarrhea x 2 during the exam

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Hakeems Growth Chart
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Case 2 Hakeem

• Is there evidence of HIV infection?
• Does he require further tests to determine
  whether he has HIV infection?
• Are there other problems or concerns?
• What should be done at this visit?

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Case 2 Hakeem

• His growth is poor. You find that he used to
  grow along the 15th percentile for age, now he
  is on the 3rd percentile (diarrhea could explain
  the weight loss)
• Since hes not very sick you decide to give him
  some ORS
• You continue cotrimoxazole and stress the
  importance of adherence
• You provide psychosocial support including
  counseling around disclosure to other caretakers
• You arrange follow up for 1 month

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Case 2 Hakeem

• Hakeem returns after a month. He is now 6 months
  old
• His mother says the diarrhea has subsided
• When you examine him he still has not gained any
  weight
• His weight is now below the 3rd percentile
• He has some thrush and bilateral enlarged
  axillary adenopathy
• You are concerned he may have HIV because of poor
  growth and generalized lymphadenopathy

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Hakeems Growth Chart
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Case 2 Hakeem

• What should you do?
• What will you tell the mother?

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Case 2 Hakeem

• You send another DBS DNA-PCR
• You evaluate his diet, provide nutritional
  counseling and help mom obtain food supplements
  for the family
• You review cotrimoxazole prophylaxis and
  importance of adherence
• You schedule follow-up for 2 weeks

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Case 2 Hakeem

• Hakeem returns for follow-up visit
• The DNA PCR test is positive
• He is still not gaining weight and is not looking
  very well

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Case 2 Hakeem

• Does Hakeem have HIV?
• What will you tell the mother?
• What should be done at this visit?

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Case 2 Hakeem

• You explain to his mother that Hakeem has HIV
  infection
• You send a repeat DNA PCR to confirm the
  diagnosis
• You counsel the mother, and refer Hakeem for HIV
  care and treatment at the HIV Care and Treatment
  Center. One of the outreach workers takes mom to
  the pediatric clinic at the medical center where
  the baby gets an appointment for the following
  day.

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Case 3 Ali

• Ali is a 10 month old admitted to the pediatric
  ward from a dispensary for diarrhea and
  dehydration
• His mother tested positive for HIV 3 months ago
  and no pMTCT interventions were available she
  does not know her clinical stage or her CD4 count
  and currently does not receive ART. She appears
  thin and wasted.
• Mother has limited food access and few financial
  resources
• Alis PE Severely wasted, vigorously
  breastfeeding in clinic, but crying and irritable
  throughout
• HEENT thrush over entire buccal mucosa
• Lymph generalized lymphadenopathy
• Chest clear, no murmurs
• Abdomen hepatosplenomegaly
• Neurological/Developmental decreased tone, could
  not sit (previously sat at 5 months), weak cry,
  does not engage socially

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Case 3 Ali

• Growth Measurements
• Birth 4.8 kg ( 97)
• 2 months 7 kg ( 97)
• 7 months 5.9 kg (
• 8 months 6 kg (
• 10 months 4.5 kg (weight!), Ht. 62 cm (

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Alis Growth Curve
Birth 4.8 kg 2 mo 7 kg 2 7 mo 5.9 kg 8 mo
6 kg 10mo 4.5kg
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Case 3 Ali

• What are your impressions?
• Is there evidence of HIV-infection?
• What is your plan?

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Case 3 Ali

• Plan
• Rapid HIV Antibody test to confirm HIV-exposed
  status
• DNA PCR if available
• CD4, baseline laboratory investigations
• Baseline CXR
• Admission for oral rehydration therapy and
  nutritional supplementation, multivitamins
• Initiate cotrimoxazole
• Ensure mother is engaged in HIV care, provide
  referrals to appropriate community resources

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Case 4 Prosper

• Prosper is a 15 month old HIV-exposed infant here
  for well baby check
• Prospers Medical and Birth History
• Both mother and infant received PMTCT, C-section
  delivery (due to prior C/S), Birth weight 3.6 kg
  No illnesses since birth
• Feeding history Exclusive breastfeeding until 6
  months, complementary feeds started at 6 months
  with continued breast feeding
• Maternal history mother healthy WHO Clinical
  Stage 1, CD4 605 no ARVs
• Prospers history since last visit no illnesses,
  adequate food supply and financial support
• A DNA-PCR was done at 3 months and was negative

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Case 4 Prosper

• Prosper was followed in the clinic until he was
  12 months when his family moved away form the
  clinic catchment area
• His mother stopped breastfeeding him when he was
  13 months old
• The family has moved back
• His mother remembers a nurse telling her that he
  needs to be checked out when she weans him form
  the breast, so she bring him to the clinic
• Physical Exam general appearance is of a well
  and robust baby
• Developmental walking, says bye bye, engaging
  and curious
• Growth Measurements
• Birth 3.6 kg
• 1 month 4.6 kg
• 2 months 5.6 kg
• 3 months 6.4 kg
• 6 months 8kg
• 9 months 8.8 kg
• 12 months 9.5kg

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Prospers Growth Curve
Birth 3.6 kg 1 mo 4.6 kg 2 mo 5.6 kg 3 mo
6.4 kg 6 mo 8 kg 9mo8.8kg 12 mo9.5kg
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Case 4 Prosper

• What are your impressions?
• What will you do for Prosper?

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Case 4 Prosper

• You obtain a rapid antibody test
• The results of the rapid antibody test is
  negative.
• Since he stopped breastfeeding 2 months ago, you
  can confidently say he is not infected
• You discharge him to the under-five clinic