Pediatric Annals

EDITORIAL 

A Pediatrician's View: Collaboration Between Pediatric Subspecialists and Generalists in the Care of HIV-Infected Children

Robert A Hoekelman, MD

Abstract

This issue of Pediatric Anncds has as its Guest Editors E. Richard Stiehm, MD, Professor of Pediatrics at the UCLA School of Medicine, and Lisa M. Frenkel, MD, Assistant Professor of Pediatrics at the University of Rochester School of Medicine and Dentistry. It addresses human immunodeficiency virus (HlV) infection in infants, children, and adolescents. Prior issues of Pediatric Annals directed to this subject were published in May 1988 and in July and August 1990. The predictions that were made then regarding the number of HIV infections we would have in this age group today - 20 000 - held up, while the number of cases of acquired immunodeficiency syndrome (AIDS) - more than 4000 in children less than 13 years of age - has exceeded those predictions. These numbers will increase rapidly, primarily through mother- to- infant transmission in utero and during delivery, and by adolescents injecting street drugs and engaging in hetero- and homosexual intercourse. Widely diverse social and geographic populations of pediatric patients will be affected.

The clinical presentations of HIV infection are manifold.1 They include:

* failure to thrive,

* progressive encephalopathy, seizure disorders, stroke, aseptic meningitis, and learning disorders,

* dermatologie conditions, including candidiasis, varicella, shingles, molluscum contagiosum, seborrheic dermatitis, eosinophilic folliculitis, and drug hypersensitivity reactions,

* blepharitis, conjunctivitis, and retinitis,

* upper respiratory tract manifestations, including chronic otitis media, sinusitis and mastoiditis, conductive hearing loss, hypertrophied tonsils and adenoids (with sleep apnea), and hoarseness, thrush, recurrent aphthous ulcers, dental caries, gingivitis, parotitis, and cervical adenitis,

* lower respiratory tract manifestations, including recurrent bacterial pneumonia (in particular Pneu* mocystis carinii pneumonia), viral pneumonia, Mycobacterium avium complex, tuberculosis, reactive airway disease, lymphoid interstitial pneumonitis, pulmonary fibrosis, and pulmonary hypertension,

* cardiomyopathy with congestive heart failure,

* enteritis and enterocolitis due to a variety of organisms,

* acute and chronic hepatitis caused by cytomegalovirus and hepatitis B virus,

* pancreatitis,

* nonspecific myopathy and myositis,

* nephrotic syndrome,

* pancytopenia,

* bleeding disorders, and

* malignancies, including non-Hodgkin's, central nervous system, and gastrointestinal tract lymphomas, Kaposi's sarcoma, leiomyoma, and leiomyosarcoma.

By any measure, this list of maladies is awesome, and many are beyond the scope of the primary care pediatrician's management skills. Human immunodeficiency virus seropositivity in infants, children, and adolescents suspected of being infected must be determined and monitored, and the clinical category of HlV infection, including the diagnosis of AIDS, must be classified for case reporting purposes. The Centers for Disease Control and Prevention has developed a classification system for HIV infection in children under 1 3 years of age2 and recently revised its classification system for HlV infection and AIDS in adolescents and adults.3 These classifications rely on CD4+ T-cell counts and the presence of specific diseases afflicting the patient. It is a complicated system that relies largely on diagnostic methods not within the primary care practitioner's armamentarium. Furthermore, the treatment of HIV-infected infants, children, and adolescents is complex, calling for a variety of anti-HIV drugs and antibiotics, and the use of intravenous immunoglobulin and, often, parenteral nutritional therapy. We are still in the stage of investigating the best approaches to treating these patients, using standardized protocols and monitoring outcomes. This currently is being done at university medical centers by pediatric infectious disease subspecialists and other tertiary care physicians and by a multidisciplinary team of allied health professionals.

What then is the role of primary care physicians in the management of their HIV-infected patients? Their role should be the same as the one they play in caring for their patients who have childhood cancer and those who have other severe chronic illnesses.4 They need to…

This issue of Pediatric Anncds has as its Guest Editors E. Richard Stiehm, MD, Professor of Pediatrics at the UCLA School of Medicine, and Lisa M. Frenkel, MD, Assistant Professor of Pediatrics at the University of Rochester School of Medicine and Dentistry. It addresses human immunodeficiency virus (HlV) infection in infants, children, and adolescents. Prior issues of Pediatric Annals directed to this subject were published in May 1988 and in July and August 1990. The predictions that were made then regarding the number of HIV infections we would have in this age group today - 20 000 - held up, while the number of cases of acquired immunodeficiency syndrome (AIDS) - more than 4000 in children less than 13 years of age - has exceeded those predictions. These numbers will increase rapidly, primarily through mother- to- infant transmission in utero and during delivery, and by adolescents injecting street drugs and engaging in hetero- and homosexual intercourse. Widely diverse social and geographic populations of pediatric patients will be affected.

The clinical presentations of HIV infection are manifold.1 They include:

* failure to thrive,

* progressive encephalopathy, seizure disorders, stroke, aseptic meningitis, and learning disorders,

* dermatologie conditions, including candidiasis, varicella, shingles, molluscum contagiosum, seborrheic dermatitis, eosinophilic folliculitis, and drug hypersensitivity reactions,

* blepharitis, conjunctivitis, and retinitis,

* upper respiratory tract manifestations, including chronic otitis media, sinusitis and mastoiditis, conductive hearing loss, hypertrophied tonsils and adenoids (with sleep apnea), and hoarseness, thrush, recurrent aphthous ulcers, dental caries, gingivitis, parotitis, and cervical adenitis,

* lower respiratory tract manifestations, including recurrent bacterial pneumonia (in particular Pneu* mocystis carinii pneumonia), viral pneumonia, Mycobacterium avium complex, tuberculosis, reactive airway disease, lymphoid interstitial pneumonitis, pulmonary fibrosis, and pulmonary hypertension,

* cardiomyopathy with congestive heart failure,

* enteritis and enterocolitis due to a variety of organisms,

* acute and chronic hepatitis caused by cytomegalovirus and hepatitis B virus,

* pancreatitis,

* nonspecific myopathy and myositis,

* nephrotic syndrome,

* pancytopenia,

* bleeding disorders, and

* malignancies, including non-Hodgkin's, central nervous system, and gastrointestinal tract lymphomas, Kaposi's sarcoma, leiomyoma, and leiomyosarcoma.

By any measure, this list of maladies is awesome, and many are beyond the scope of the primary care pediatrician's management skills. Human immunodeficiency virus seropositivity in infants, children, and adolescents suspected of being infected must be determined and monitored, and the clinical category of HlV infection, including the diagnosis of AIDS, must be classified for case reporting purposes. The Centers for Disease Control and Prevention has developed a classification system for HIV infection in children under 1 3 years of age2 and recently revised its classification system for HlV infection and AIDS in adolescents and adults.3 These classifications rely on CD4+ T-cell counts and the presence of specific diseases afflicting the patient. It is a complicated system that relies largely on diagnostic methods not within the primary care practitioner's armamentarium. Furthermore, the treatment of HIV-infected infants, children, and adolescents is complex, calling for a variety of anti-HIV drugs and antibiotics, and the use of intravenous immunoglobulin and, often, parenteral nutritional therapy. We are still in the stage of investigating the best approaches to treating these patients, using standardized protocols and monitoring outcomes. This currently is being done at university medical centers by pediatric infectious disease subspecialists and other tertiary care physicians and by a multidisciplinary team of allied health professionals.

What then is the role of primary care physicians in the management of their HIV-infected patients? Their role should be the same as the one they play in caring for their patients who have childhood cancer and those who have other severe chronic illnesses.4 They need to work collaboratively with the subspecialist team by 1 ) being knowledgeable about the status of the patient's condition and the treatment being rendered for it, and 2) supplying interim health services, such as immunizations, treating minor acute illnesses, providing anticipatory guidance in physical and psychosocial development, and counseling and supporting the patient and the family during their most difficult crises. These functions should be agreed on with the subspecialist team early on, explained to the family, and stuck to.

REFERENCES

1. Church JA. Clinical manifestations of HlV infection in children. I'ediaa Ann. 1993;22:417-427.

2. Centers for Disease Control. Classification system for human immunodeficiency virus (HIV) in children under 1 3 years of age. MMWR. 1987;36:225-2 36.

3. Centers tor Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR. 1992;41:1-19.

4. KanthoT HA, Pless ft, Satumririie B, Myers O. Areas of raparuitality in the Wealth care of multiply handicapped children. Pediatrics. 1974;54:779-785.

10.3928/0090-4481-19930701-04

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