Maternal HIV/AIDS Status and Neurological Outcomes in Neonates: A Population-Based Study

Neurobehavioural challenges experienced by HIV exposed infants: a study in South Africa

BACKGROUND

The newborn infant is a complexly organized, competent being, who plays an active role in shaping their environment through their increasing skills in autonomic regulation, motor control, regulation of state and social interaction. Infants born to HIV positive mothers, are exposed to HIV and antiretroviral therapy inutero, and may experience adverse effects from this.

METHODS

A cross-sectional study of 132 mother-infant dyads from a large public health hospital in South Africa. Infants were assessed using the Neonatal Behavioural Assessment Scale on day two of life, and mothers mental health assessed using the Edinburugh Postnatal Depression Scale. Medical and demographic data on mothers and infants was collected, including maternal age, HIV status, length of time on antiretrovirals, relationship status, employment status, gravid status, mode of delivery, infant anthropometrics and infant gender. Data was input into IBM SPSS statistics 21, where frequencies and percentages for descriptive analysis, and Chi-square and student's two sample t-tests were run to compare data from HIV infected-exposed and HIV uninfected-unexposed mothers and infants.

RESULTS

HIV exposed infants were smaller than HIV unexposed infants, even though low birth weight was an exclusion criteria. Statistically significant differences were found between HIV exposed and unexposed infants in neurobehavioiral items of social interaction (p = 0.00), motor system (p = 0.00) and state organization (p = 0.01), with HIV exposed infants performing less optimally in these domains. HIV exposed infants also presented with more abnormal reflexes. Infants born to depressed mothers showed superior motor skills, state organization and state regulation than infants born to mothers who did not score in the possibly depressed range.

CONCLUSIONS

HIV exposed infants have inferior neurobehavioural functioning, which may affect their quality of life and ability to develop a reciprocal relationship with a primary caregiver. This may have an effect on development, behaviour and mental health in later childhood. HIV exposed infants shoud be monitored closely and their functioning in autonomic stability, motor control, resualtion of state and social interaction assessed regularly. Guidance for caregivers in incorporating strategies into the care of these infants is essential to buffer the possible long term negative effects on development.

Maternal mental health and caregiver competence of HIV-positive and negative women caring for their singleton newborns in KwaZulu-Natal Province, South Africa

Background. Maternal mental health during the perinatal period has been of interest to many researchers, with antenatal depression and postnatal depression (PND) being a leading cause of morbidity. The adverse effects of maternal depression on the offspring throughout infancy, childhood and adolescence are well documented. Studies on the mental health of persons living with HIV have also reported a high prevalence of depression. Objectives. To describe the prevalence of PND in a sample of HIV-positive and HIV-negative mothers delivering healthy singleton infants at one obstetric unit in KwaZulu-Natal (KZN) Province, South Africa, and the subsequent factors influencing neonatal behaviour and perceptions of caregiver competence. Correlations between the presence of PND and perceptions of caregiver competence (with the mother as caregiver), and between infant behaviour, the mother’s confidence in her competence as caregiver, and demographic and medical variables, were also examined. Methods. Demographic and clinical data were collected from 132 mothers at initial contact and from 32 mothers at the 6-week follow-up appointment. Mothers independently completed the Edinburgh Postnatal Depression Scale at each time point, and the Mother and Baby Scales (MABS) at the 6-week follow-up appointment.Results. The prevalence of depression among all mothers at initial contact was 72.0%, remaining high (68.8%) among the mothers who returned for follow-up. There was a statistically significant correlation between depression and employment at follow-up (p=0.013), and between depression and delivery method (p=0.030). The majority of mothers reported being ‘able to laugh and see the funny side of things’ and ‘looking forward with enjoyment to things’ at initial contact and follow-up. Thoughts of self-harm were reported by 44.7% of mothers at baseline, and by 53.1% at follow-up. Although most infants scored in the average clinical band for neonatal behavioural factors in the MABS, mothers reported lack of confidence, globally and in caring for their infant. Conclusion. This study of maternal mental health of a sample of HIV-positive and HIV-negative mothers of infants in KZN revealed a higher prevalence of PND than reported in other studies. This population of mothers and infants is at risk of adverse outcomes of maternal depression, in addition to other possible risk factors.

Developmental status of human immunodeficiency virus-exposed uninfected premature infants compared with premature infants who are human immunodeficiency virus unexposed and uninfected

Background

There is growing concern about the developmental outcome of infants exposed to HIV in utero. HIV-infected women are at greater risk of premature delivery which poses a further developmental risk factor.

Objectives

To determine whether there is a difference between the development of premature infants born at 28–37 weeks gestational age that are HIV exposed but uninfected (HEU) compared with HIV-unexposed uninfected infants (HUU).

Method

A cross-sectional study was conducted in a Johannesburg state hospital. Thirty HEU and 30 HUU infants, aged between 16 days and six months, were assessed using the Bayley Scales of Infant and Toddler Development III.

Results

The two groups were well matched for gestational age and birth weight; however, more HUU infants presented with neonatal complications. HUU infants had lower developmental scores than HEU infants in the language (p = 0.003) and motor (p = 0.037) subscales. Expressive language was more affected in the HUU infants (p = 0.001), and fine (p = 0.001) and gross motor (p = 0.03) were affected as well. HUU infants with neonatal complications such as meningitis (p = 0.02) and neonatal jaundice (NNJ) (p = 0.01) are more likely to present with language and motor delay.

Conclusion

Meningitis and NNJ have more impact on infant development than in-utero HIV and ARV exposure.

Clinical implications

It is important for all premature infants to be screened regularly in order to diagnose developmental delays early so as to ensure early intervention and improved quality of life.

Prevalence and associated prenatal and perinatal risk factors for oropharyngeal dysphagia in high-risk neonates in a South African hospital

Background

The prevalence of neonatal oropharyngeal dysphagia (OPD) in high-risk infants in lower-middle-income countries is unknown.

Objectives

To determine the prevalence and associated risks for OPD in high-risk neonates in order to allow timely intervention for OPD, minimising negative outcomes.

Method

A prospective cross-sectional observational study was conducted in an urban hospital in South Africa. Clinical feeding assessments were conducted using the Neonatal Feeding Assessment Scale with all available neonates in neonatal care.

Results

The sample of 81 high-risk neonates (mean chronological age = 11.7 days; standard deviation = 15.6 days) had been feeding orally for 2 days and were approaching discharge. Fifty-two participants (64.2%) had OPD. Risks likely associated with OPD included breech presentation, septicaemia and other infections, spending more than 1 day on a warm table or incubator, neurological conditions, prenatal exposure to maternal smoking, siblings with mental or neurological disability, participants with congenital disorders, preterm birth (< 37 weeks), low birth weight (< 2500 g), or retinopathy of prematurity.

Conclusion

An unexpected high prevalence of OPD was found in neonates already deemed ready for oral feeding and approaching discharge. Timely early involvement of the Speech-Language Therapists (SLTs) in decision-making about feeding readiness may prevent serious complications of neonatal OPD. Findings may inform South African neonatal clinicians. The study provides motivation for early intervention from SLTs before the infant and mother are discharged from high care and dispersed to communities where intervention services may be scarce.

Maternal hepatitis B and hepatitis C infection and neonatal neurological outcomes

To examine the associations between maternal hepatitis B (HBV) and hepatitis C (HCV) infection status and selected infant neurological outcomes diagnosed at birth, we conducted a population-based, retrospective cohort study on singleton live births in Florida from 1998 to 2009. Primary exposures included maternal HBV and HCV monoinfection. The neurological outcomes included brachial plexus injury, cephalhematoma, foetal distress, feeding difficulties, intraventricular h aemorrhage and neonatal seizures. Multivariable logistic regression models were used to generate odds ratios (OR) and 95% confidence intervals (CI) that were adjusted for socio-demographic characteristics, risky behaviours, pregnancy complications and pre-existing medical conditions, and timing of delivery. The risk of an adverse neurological outcome was higher in infants born to mothers with hepatitis viral infection (7.2% for HCV, 5.0% for HBV), compared with infants of hepatitis virus-free mothers (4.2%). After adjusting for potential confounders, women with HBV were twice as likely to have infants who suffered from brachial plexus injury (OR = 2.04, 95% CI = 1.15-3.60), while those with HCV had an elevated odds of having an infant with feeding difficulties (OR: 1.32, 95% CI = 1.06-1.64) and a borderline increased likelihood for neonatal seizures (OR = 1.74, 95% CI = 0.98-3.10). Additionally, HCV+ mothers had a 22% increased odds of having an infant with some type of adverse neurological outcome (OR: 1.22, 95% CI = 1.03-1.44). Our findings add to current understanding of the association between maternal HBV/HCV infections and infant neurological outcomes. Further research evaluating the role of maternal HBV and HCV infections (including viraemia, treatment) on pregnancy outcomes is warranted.

Intra-uterine exposure to maternal opiate abuse and HIV: the impact on the developing nervous system

BACKGROUND

Both intra-uterine exposure to maternal drugs and HIV are known to adversely affect the developing central nervous system.

AIMS

(1) To describe the quality of GMs in infants who were intra-uterinely exposed to maternal opiate abuse and HIV; and (2) to analyze to what extent (a) perinatal events, (b) status of HIV-infection, and (c) the quality of GMs are associated with the neurodevelopmental outcome at 2 to 3years of age.

PATIENTS AND METHOD

Seventy-seven children intra-uterinely exposed to both maternal opiate abuse and HIV in utero (41 boys and 36 girls; 39 born preterm) were videoed twice: first during the first 2months after term (writhing GMs) and again at 3-5months (fidgety GMs). Neurodevelopmental outcome was assessed at 2-3years of age.

RESULTS

Thirty-eight infants showed abnormal writhing GMs; 25 infants had abnormal or absent fidgety movements; 22 children had an adverse neurodevelopmental outcome. The association between GM trajectories and outcome revealed a Cramer-V=0.75 (p<0.001). Those infants with active HIV-infection (n=10) did not differ from the 67 infants who were HIV-exposed but uninfected with respect to their GM quality or outcome.

CONCLUSIONS

Serial assessment of GMs in infants who were intra-uterinely exposed to maternal opiates and to HIV can be utilized for early identification of infants at a higher risk for later deficits and needing early intervention.