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Treatment of HIV/AIDS in Children (ARV therapy)

hiv / aids Treatment in Children

Treatment Modalities of HIV/AIDS

Treatment Modality	Description
Antiretroviral Therapy (ART)	Suppresses viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.
Treatment of Acute Bacterial Infections	Addresses immediate bacterial infections.
Prophylaxis and Treatment of Opportunistic Infections	Prevents and manages opportunistic infections.
Maintenance of Good Nutrition	Ensures adequate nutrition to support overall health.
Immunization	Administers vaccines to prevent opportunistic infections.
Management of AIDS-Defining Illnesses	Addresses specific illnesses associated with advanced HIV infection.
Psychological Support for the Family	Provides emotional support and guidance for affected families.
Palliative Care for the Terminally Ill	Offers comfort and support for patients nearing the end of life.

ANTIRETROVIRAL DRUG TREATMENT

The goal of ART

Goal of ART: Suppress viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

When to Initiate ARV:

All HIV-infected children below 12 months.
Clinical AIDS
Mild to moderate symptoms and immunosuppression.

Process of Starting ART:

Assess all clients for opportunistic infections especially TB and cryptococcal meningitis. If the patient has TB or cryptococcal meningitis, ART should be deferred and initiated after starting treatment for these OIs. Treatment for other OIs and ART can be initiated concurrently.
For patients without TB or cryptococcal meningitis, offer ART on the same day through an opt-out approach. In this approach, the patients should be prepared for ART on the same day and assessed for readiness to start ART using the readiness checklist
If a client is ready, ART should be initiated on the same day. If a client is not ready or opts out of same-day initiation, a timely ART preparation plan should be agreed upon with the aim of initiating ART within seven days for children and pregnant women, and within one month for adults.

Principles for selecting the ARV regimens

The first-line ART regimens for treating HIV infection in Uganda were selected based on the following principles:

∙ Regimen with lower toxicity
∙ Better palatability and lower pill burden
∙ Increased durability and efficacy
∙ Sequencing: spares other available formulations for use in the 2nd line regimen ∙ Harmonization of regimen across age and population
∙ Lower cost
∙ Help the country to achieve a recommended regimen for the vast majority of PLHIV(People Living With HIV)

Available ARVs in Uganda

Drug Class	Examples
Nucleoside Reverse Transcriptase Inhibitors (NRTIs): Incorporate into the DNA of the virus, thereby stopping the building process.	Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC)
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stop HIV production by binding directly onto the reverse transcriptase enzyme, and prevent the conversion of RNA to DNA.	Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV)
Integrase Inhibitors: interfere with the HIV DNA’s ability to insert itself into the host DNA and copy itself.	Dolutegravir (DTG), Raltegravir (RAL)
Protease Inhibitors (PIs): prevent HIV from being successfully assembled and released from the infected CD4 cell.	Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV)
Entry Inhibitors: prevent the HIV virus particle from infecting the CD4 cell.	Enfuvirtide (T-20), Maraviroc

Uses of ART (Antiretroviral Therapy)

Treatment of HIV/AIDS: ART is the primary treatment for managing HIV/AIDS, helping to control the viral load and maintain the health of the immune system.
Prevention of Mother-to-Child Transmission (PMTCT): ART is crucial in preventing the transmission of HIV from an infected mother to her baby during pregnancy, childbirth, and breastfeeding.
Post-Exposure Prophylaxis (PEP): ART is used as an emergency intervention for individuals who have been potentially exposed to HIV. It must be started within 72 hours of exposure to be effective.
Pre-Exposure Prophylaxis (PrEP): ART can be taken by HIV-negative individuals at high risk of infection to prevent acquiring HIV. This is particularly useful for people with HIV-positive partners, among others.
Treatment and Support for Children: Ensuring children with HIV receive ART is essential for their growth, development, and long-term health. Adherence to the treatment regimen is crucial for its effectiveness.
Reducing Viral Load to Undetectable Levels: ART helps reduce the viral load in the body to undetectable levels, significantly lowering the risk of HIV transmission and improving overall health.
Improving Quality of Life: Effective ART can improve the quality of life for people living with HIV by reducing the incidence of opportunistic infections and other HIV-related complications.
Increasing Life Expectancy: ART has been shown to increase the life expectancy of people living with HIV, allowing them to live longer, healthier lives.
Preventing Sexual Transmission of HIV: By reducing the viral load to undetectable levels, ART can prevent the sexual transmission of HIV, a strategy known as “treatment as prevention” (TasP).
Reducing HIV-Related Stigma and Discrimination: Successful ART can help reduce stigma and discrimination associated with HIV by enabling individuals to lead healthy, productive lives, thereby changing perceptions about the disease.
Managing Co-Infections: ART can help in managing co-infections such as hepatitis B and C, tuberculosis, and other conditions that are common in people living with HIV.

Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children

HIV management guidelines are constantly being updated according to evidence and public policy decisions. Always refer to the latest official guidelines.

The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an integrase inhibitor as the anchor ARV in the preferred first and second-line treatment regimens for all HIV infected clients; children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls and women of child bearing potential).

Patient Category	Preferred Regimens	Alternative Regimens
Adults and Adolescents
Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg)	TDF + 3TC + DTG	– If DTG is contraindicated: TDF + 3TC + EFV400 – If TDF is contraindicated: TAF + FTC + DTG – If TDF or TAF is contraindicated: ABC + 3TC + DTG – If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r
Children
Children ≥20Kg – <30Kg	ABC + 3TC + DTG	– If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) – If ABC and TAF are contraindicated: AZT + 3TC + DTG
Children <20Kg	ABC + 3TC + DTG	– If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules – If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r

Notes:

Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.
Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg.
TAF can be used in subpopulations with bone density anomalies.
Children will be assessed individually for their ability to correctly take the different formulations of LPV.

Notes from Ministry of Health

For clients on an ABC-3TC-DTG based regimen weighing >25 kg, use the fixed-dose combination of Abacavir/Lamivudine/Dolutegravir 600/300/50 mg instead of the separate pills of Abacavir/Lamivudine 600/300 mg plus Dolutegravir 50 mg.
Use Abacavir/Lamivudine 600/300 mg for patients on the following regimens: ABC-3TC-ATV/r, ABC-3TC-LPV/r, and ABC-3TC-DRV/r.
Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
For PrEP, while the guidelines provide options for the use of either TDF/3TC 300/300 mg or TDF/FTC 300/200 mg, use TDF/FTC 300/200 mg for PrEP in terms of programmatic implementation.

RECOMMENDED FIRST-LINE REGIMEN FOR INITIATION OF ART IN CHILDREN UNDER 3 YEARS OF AGE

Recommended first-line regimen: ABC+3TC+LPV/r

All HIV-infected children under 3 years should be initiated on abacavir + lamivudine + ritonavir-boosted lopinavir (ABC+3TC+LPV/r).

NB: Children younger than 36 months have a reduced risk of discontinuing treatment, viral failure or death if they start on an LPV/r based regimen instead of the NVP-based regimen. Also, surveillance of drug resistance among vertically infected children younger than 18 months in

Uganda has revealed high levels of resistance to NNRTIs and LPV/r is known to have a high barrier to resistance.

When to use alternative first-line regimens AZT+3TC+LPV/r

AZT+3TC+ LPV/r should only be used in children who experience a hypersensitivity reaction to abacavir (ABC), however, this is rare in African populations.

WHAT REGIMEN TO SWITCH TO (SECOND-LINE AND THIRD-LINE ART)

Second-line ARVS in adolescents/children above 10 years

Recommended 2nd line regimen: 2 NRTIs +ATV/r

HIV-infected adolescents/children above 10 years, initiating 2nd line ART should be initiated on 2 NRTIs and ritonavir-boosted atazanavir (ATV/r). The choice of NRTI should be determined based on the regimen the patient was on.

The recommended sequence is:

After failing on TDF + 3TC or ABC+3TC based regimen, use AZT+3TC
After failing on AZT+3TC based regimen, use TDF + 3TC

When to use alternative 2nd line regimen: 2 NRTIs +LPV/r

LPV/r is should only be used to initiate adolescents/children who weigh less than 40kg.

Second-line ARVS in children aged 3 years to less than 10 years

RECOMMENDED 2nd line REGIMEN: 2 NRTIs +LPV/r

HIV-infected children aged 3 to less than 10 years initiating 2nd line ART should be initiated on 2 NRTIs and ritonavir-boosted lopinavir (LPV/r). The recommended formulation is the LPV/r 100/25mg tablet. The choice of NRTI should be determined based on the regimen the patient was on The recommended sequence of the NRTIs is below:

∙ After failing on ABC+3TC based regimen, use AZT+3TC.

∙ After failing on AZT+3TC based regimen, used ABC+3TC.

Second-line ARVS in children under 3 years

Recommended 2nd line regimen: 2 NRTIs +RAL

HIV-infected children less than 3 years of age initiating 2nd line ART should be initiated on 2 NRTIs and RAL. The choice of NRTI should be determined based on the regimen the patient was on (Table 55). The recommended sequence of the NRTIs is:

∙ After failing on ABC+3TC based regimen, use AZT+3TC.

∙ After failing on AZT+3TC based regimen, used ABC+3TC.

The rationale for using raltegravir

Raltegravir is the recommended drug of choice for the second line ARVs in children with prior exposure to protease inhibitors because there is no data on safety and efficacy of dolutegravir in children under six years, while darunavir is contraindicated in this age group.

When to use alternative 2nd line regimen: 2 NRTIs + LPV/r

LPV/r is recommended in children who have used NNRTI (NVP) in their first line regimen.

Monitoring of ARV Treatment

The monitoring of patients on antiretroviral therapy (ART) serves several purposes:

Assess Response to ART and Diagnose Treatment Failure
Ensure Safety of Medicines: Identify Side Effects and Toxicity
Evaluate Adherence to ART

Methods of Monitoring ARV Treatment

1. Clinical Monitoring: Involves medical history and physical examination.

2. Laboratory Monitoring: Includes various laboratory tests.

Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
CD4 Monitoring: Recommended in specific scenarios.
Other Minor Laboratory Tests: Includes tests for specific indications.

Viral Load Monitoring

Preferred method for monitoring ART response. A patient who has been on ART for more than 6 months and is responding to ART should have viral suppression (VL <1000 copies/ml) irrespective of the sample type (either DBS or plasma).
Provides an early and more accurate indication of treatment failure and the need to switch from first line to second-line drugs, hence reducing the accumulation of drug resistance mutations and improving clinical outcomes.
Early and accurate indication of treatment failure.
Differentiates between treatment failure and non-adherence.
Recommended frequency: Every six months for children and adolescents under 19 years.

CD4 Monitoring

Baseline CD4 count is essential for assessing opportunistic infection risk.
Recommended for patients with high viral load or advanced clinical disease.

Other Laboratory Tests

Tests	Indication
CrAg	Screen for cryptococcal infection
Complete Blood Count (CBC)	Assess anaemia risk
TB Tests	Suspected tuberculosis
Serum Creatinine	Assess kidney function
ALT, AST	Evaluate liver function
Lipid Profile, Blood Glucose	Assess metabolic health

Problems Associated with ARV Treatment

Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is a spectrum of clinical signs and symptoms linked to immune recovery triggered by ART. It occurs in 10–30% of individuals starting ART, usually within the first 4–8 weeks.

Serious Forms: Most severe cases happen in patients co-infected with TB, Cryptococcus, Kaposi’s sarcoma, and herpes zoster.
Risk Factors: Include low CD4+ cell count (<50 cells/mm3) at ART initiation and disseminated opportunistic infections.
Management: Usually self-limiting; treat co-infections to reduce symptoms and reassure patients to maintain ART adherence.

Steps to Reduce IRIS Development

Early HIV Diagnosis: Initiate ART before CD4 declines to below 200 cells/mm3.
Optimal Management of Opportunistic Infections: Screen and treat infections before starting ART, especially TB and cryptococcus.

ARV Drug Toxicity

Range of Toxicities: ARVs can cause mild to life-threatening side effects.
Challenges: Differentiating between ARV toxicity and HIV complications can be complex.
Management: Assess patients for side effects at every clinic visit and take appropriate actions based on severity.

Management of ARV Side Effects/Toxicities

Category	Action
Severe, Life-threatening Reactions (e.g., SJS/TEN, severe hepatitis)	– Discontinue all ARVs immediately. – Manage the medical event and substitute offending drug when stable.
Severe Reactions (e.g., Hepatitis and Anemia)	– Substitute offending drug without stopping ART.
Moderate Reactions (e.g., Gynaecomastia, Lipodystrophy)	– Substitute with a drug in the same class or different class with a different toxicity profile. – Do not discontinue ART; continue if feasible.
Mild Reactions (e.g., Headache, Minor Rash, Nausea)	– Do not discontinue or substitute ART. – Provide reassurance and support to mitigate adverse reactions. – Counseling about the events.

Management of HIV Positive Pregnant Mother

Key Interventions for eMTCT:

Routine HIV Counseling and Testing during ANC (at 1st contact. If negative, repeat HIV test in the third trimester/ labour).
Enrolment in HIV care if the mother is positive and not yet on treatment.
If the mother is already on ART, perform viral load and continue the current regimen.
ART in pregnancy, labour, post-partum, and for life – Option B+.

Recommended ARV for option B+:

One daily Fixed Dose Combination (FDC) pill containing TDF + 3TC + EFV started early in pregnancy irrespective of the CD4 cell count and continued during labor and delivery, and for life.

Alternative regimens for women who may not tolerate the recommended option are:

If TDF contraindicated: ABC+3TC+EFV
If EFV contraindicated: TDF + 3TC + ATV/r
TDF and EFV are safe to use in pregnancy.
Those newly diagnosed during labor will begin HAART for life after delivery.

Prophylaxis for Opportunistic Infections

Cotrimoxazole 960 mg 1 tab daily during pregnancy and postpartum –– Mothers on cotrimoxazole DO NOT NEED IPTp with SP for malaria.

Care of HIV Exposed Infant

HIV-exposed infants should receive care at the mother-baby care point together with their mothers until they are 18 months old. A mother-baby care point is a healthcare facility that provides comprehensive services to both HIV-exposed infants and their parents.

The goals of HIV-exposed infant care services are:

To prevent the infant from being HIV infected.
Among those who get infected: to diagnose HIV infection early and treat it.
Offer child survival interventions to prevent early death from preventable childhood illnesses.

The HIV Exposed Infant and the mother should consistently visit the health facility at least nine times during that period i.e (i.e., at 6, 10 and 14 weeks, then at 5, 6, 9, 12, 15 and 18 months).

Nevirapine Prophylaxis

Provide NVP syrup from birth for 6 weeks: Give NVP for 12 weeks for babies at high risk, that is breastfeeding infants who mothers:

Have received ART for 4 weeks or less before delivery; or
Have VL >1000 copies in 4 weeks before delivery; or
Diagnosed with HIV during 3rd trimester or breastfeeding period (Postnatal)

Do PCR at 6 weeks (or at first encounter after this age) and start cotrimoxazole prophylaxis

If PCR positive, start treatment with ARVs and cotrimoxazole and repeat PCR (for confirmation)
If PCR negative and the baby never breastfed, the child is confirmed HIV negative. Stop cotrimoxazole, continue clinical monitoring and do HIV serology test at 18 months.
If PCR is negative but the baby has breastfed/is breast feeding, start/continue cotrimoxazole prophylaxis and repeat PCR 6 weeks after stopping breastfeeding.
Follow up any exposed child and do PCR if they develop any clinical symptom suggestive of HIV at any time and independently of previously negative results.
For negative infants, do serology at 18 months before final discharge.

Dosages of Nevirapine

Age Group	Weight Range	Dosage	Syrup Volume (10 mg/ml)
Child 0-6 weeks	2-2.5 Kg	10 mg once daily	1 ml
Child 0-6 weeks	>2.5 Kg	15 mg once daily	1.5 ml
Child 6 weeks – 12 weeks	Any weight	20 mg once daily	2 ml

Cotrimoxazole Prophylaxis: Provide cotrimoxazole prophylaxis to all HIV exposed infants from 6 weeks of age until they are proven to be uninfected.

Child <5 kg: 120 mg once daily
Child 5-14.9 kg: 240 mg once daily

Isoniazid (INH) Preventive Therapy (IPT):

Give INH for six months to HIV-exposed infants who are exposed to TB.
Isoniazid 10 mg/kg + pyridoxine 25 mg daily
For newborn infants, if the mother has TB disease and has been on anti-TB drugs for at least two weeks before delivery, INH prophylaxis is not required.

Immunization

Immunise HIV exposed children as per national immunisation schedule.

In case of missed BCG at birth, do not give if the child has symptomatic HIV.

Avoid yellow fever vaccine in symptomatic HIV.

Measles vaccine can be given even in symptomatic HIV.

Counselling on Infant Feeding Choice

Explain the risks of HIV transmission by breastfeeding (15%) and other risks of not breastfeeding (malnutrition, diarrhoea).
Mixed feeding may also increase the risk of HIV transmission and diarrhoea.
Tell her about options for feeding, advantages, and risks.
Help her to assess choices, decide on the best option, and then support her choice.

Feeding Options

Recommended option: Exclusive breastfeeding, then complementary feeding after the child is 6 months old.
Exclusive breastfeeding stopping at 3-6 months old if replacement feeding is possible after this.
If replacement feeding is introduced early, the mother must stop breastfeeding.
Replacement feeding with home-prepared formula or commercial formula and then family foods (provided this is acceptable, feasible, safe, and sustainable/affordable).

If Mother Chooses Breastfeeding

The risk may be reduced by keeping the breasts healthy (mastitis and cracked nipples raise HIV infection risk).
Advise exclusive breastfeeding for 3-6 months.

If Mother Chooses Replacement Feeding

Counsel and teach her on safe preparation, hygiene, amounts, times to feed the baby, etc.
Follow up within a week from birth and at any visit to the health facility.

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Treatment of HIV/AIDS in Children (ARV therapy)

Treatment of HIV/AIDS begins after confirmation through the following diagnostic procedures.

Diagnostic Measures / Investigations.

Criteria for diagnosis of HIV/AIDS:

∙ Clinical Stage criteria
∙ HIV blood test must be positive

A reactive rapid test result must be confirmed before a diagnosis of infection can be given. Most commonly used to screen blood for donation in order to exclude those in the window period is ELISA AglAb tests

The test that Detects the genetic material of HIV itself (rather than antibodies or antigens) are known as PCR tests PCR (polymerase chain reaction) test is a type of test under Nucleic-acid Amplification testing (NAT).

NB: These tests should be used in conjunction with the clinical status, history, and risks factors of the person being tested.

HIV testing provision steps/protocol

∙ Pre-test information and counseling
∙ HIV testing
∙ Post-test counseling (individual/couple)
∙ Linkage to other services

Step 1: Pre-test information and counseling

Help the client/patient to know the ways HIV is transmitted and basic HIV preventive measures, benefits of HIV testing, possible test results and services available, consent and confidentiality, individual risk assessment, and fill the HTS card. Allow clients/patients to ask questions.

Step 2: HIV testing

Will be done using blood. For those below 18 months, a DNA PCR test will be done and those above 18 months an antibody test will be done. Refer to the HIV testing algorithms for the different age groups.

Step 3: Post-test counseling (individual/couple)

Assess readiness to receive results. Give results simply. Address concerns, disclosure, partner testing and risk reduction. Provide information about basic HIV care and ART care; complete the HTS card and HTS register.

Step 4: Linkage to other services

Provide information about services; fill the triplicate referral form. When the patient is enrolled, enter the pre-ART enrolment number into the HTS register and subsequently into the ART register when the patient is initiated on ART.

Principles of HIV testing services (HTS)

HTS delivery shall be non-discriminatory and offered using a human rights approach that observes the 5Cs (Confidentiality, Consent, Counseling, Correct test result and Connection to appropriate services). These principles are described below.

∙ Confidentiality: All providers should ensure privacy during HTS provision. All information discussed with clients should not be disclosed to another person without the client’s consent.

∙ Consent: All persons 12 years and above should consent to HTS on their own. In situations where consent cannot be obtained, the parent or guardian (of a child), next of kin, or legally authorized person should consent.

∙ Counseling: All persons accessing HTS should be provided with quality counseling before and after testing as per the approved HTS protocol.

∙ Correct test result: HTS providers should adhere to the national testing algorithm and must follow the Standard Operating Procedure for HIV testing to ensure that clients receive correct HIV test results.

∙ Connect to other services: Providers should link HTS clients to appropriate HIV prevention, treatment, care and support services.

Places to prick a child

∙ Infants age 1-4 months, less than 6kg heels work best
∙ Infants age 5-10 months, less than 10kg toes work best
∙ Larger infants and older children use the ring or middle finger

HIV testing algorithm for infants and children below 18 months of age

A virological test (DNA/PCR) is recommended for determining HIV status in infants and children below 18 months of age. The sample for testing should be collected using dried blood spot (DBS) specimens. The 1st DNA/PCR test should be done at six weeks of age or the earliest opportunity thereafter. Interpretation of the results and further testing are guided by the testing algorithm.

∙ A POSITIVE DNA/PCR test result indicates that the child is HIV-infected. All infants with a positive DNA/PCR test result should be initiated on ART and another blood sample should be collected on the day of ART initiation to confirm the positive DNA/PCR HIV test result.

∙ A NEGATIVE 1st DNA/PCR test result means that child is not infected, but could become infected if they are still breastfeeding. Infants testing HIV negative on DNA/PCR should be retested using DNA/PCR six weeks upon cessation of breastfeeding. Infants with 2nd negative DNA/PCR test should have a final rapid antibody test performed at 18 months.

Antibody tests can be used:

In children <18months of age to:

∙ Determine HIV- exposure in infants born to mothers of unknown HIV status
∙ Exclude infection in an infant at 18 months of age if the child has ceased breastfeeding for at least 6 weeks

∙ In Children > 18 months of age to confirm HIV infection

∙ HIV DNA PCR testing should be carried out on:
∙ Every HIV-exposed baby at 6 weeks of life or at first clinic visit if > 6weeks of age

Figure showing HIV testing algorithm for children <18 months of age

Procedure for DBS collection

Warm the area
Position baby with foot down
Sterilize area with alcohol
Allow to air dry
Press lancet into foot, prick skin
Wipe away first drop
Allow large drop to collect
Add 50ul (approx 2 drops) into one circle and fill it
Fill at least 3 circles
Clean foot, do not bandage
Dispose of all contaminated material appropriately

Figure showing serial HIV testing algorithm for persons above 18 months of age

Cautions during HIV testing

∙ Never use expired HIV test kits.
∙ Avoid modification of procedures
∙ Avoid use of clotted blood.
∙ Avoid use of ‘dirty’ blood (skin flakes, powder, sweat etc.)
∙ Avoid introducing air bubbles into the devices when adding the sample.

∙ Do not

⇒ Add more or less blood
⇒ Add more or less buffer
⇒ Exchange buffers
⇒ Contaminate the buffer
⇒ Modify the incubation time

LINKAGE FROM HIV TESTING TO HIV PREVENTION, CARE AND TREATMENT

Linkage refers to the process of connecting individuals who have tested positive for HIV from one service point to another.

Linkage to care is successful if the patient/client receives the services they have been referred to receive. For all clients who test HIV-positive, linkage should occur within seven days (within the same facility) and 30 days for inter-facility or community-to- facility referrals. It is recommended to use lay providers (community- and facility-based) as linkage facilitators. The process of linkage within the same health facility is described below

Types of linkages

∙ Internal facility linkage
∙ Inter facility linkage
∙ Community facility linkage

Internal facility linkage

Inter-facility linkage refers to connecting a newly diagnosed patient at one department to another department in the same facility for HIV treatment, care, and support services.

Steps of internal linkage facilitation

Post-test counseling

∙ Provide results accurately
∙ Provide information about care available at facility and elsewhere in catchment area ∙ Describe the next care and treatment steps
∙ Discuss the benefits of early treatment initiation and cons of delayed treatment ∙ Identify and address any barriers to linkage
∙ Involve the parent and child in the decision-making process regarding care and treatment ∙ Fill in client card and include referral notes
∙ Fill in the triplicate referral form
∙ Introduce and hand the patient to a linkage facilitator
∙ If same day linkage is not possible, book an appointment for the client at the clinic and follow-up to ensure the patient attends

Patient is escorted to the HIV clinic

∙ Linkage Facilitator escorts client to ART clinic with the linkage forms
∙ Hand over client to responsible staff at that clinic

Enrolling at HIV clinic

∙ Register the patient in the pre-ART register
∙ Open an HIV/ART card/ file for the patient
∙ Offer ART preparatory counseling
∙ Conduct baseline investigations
∙ If the patient is ready to start ART, initiate ART and continue with counseling support (disclosure, psychosocial)
∙ Coordinate integrated care if require (e.g. TB/HIV treatment,
∙ PMTCT)
∙ Discuss and make an appropriate appointment with the patient

Inter facility linkage

Inter-facility linkage refers to connecting a newly diagnosed patient at one facility to another facility for HIV treatment, care, and support services.

The referring facility should track (follow up) all HIV-positive patients referred to other facilities and ensure they are enrolled in care and on ART within 30 days, using the follow up/tracking schedule.

Community-facility-community linkages

Community-facility linkage refers to connecting a client who tests HIV-positive in the community to a health facility for HIV treatment, care, and support services.

HTS programs should establish functional community health systems with linkage systems including Peer Leaders, Expert Clients, VHTs and CHEWs. These should be involved in the mobilization for the targeted outreaches and follow up to link all who testing positive. Linkage from community to facility should be done within 30 days after diagnosis.

10 point care package for comprehensive Pediatrics AIDS care

1∙ Confirm HIV status as early as possible

2∙ Monitor the child’s growth and development

3∙ Ensure Immunizations are started & completed as per schedule

4∙ Provide prophylaxis for OI

5∙ Actively look for and treat infections early

6∙ Counsel mother & family on:

∙ Optimal infant feeding
∙ Good personal & food hygiene
∙ Follow up recommendations for the child

7∙ Conduct disease staging for the infected child

8∙ Offer ARV treatment for the infected child, if needed

9∙ Provide psychosocial support for the infected child and mother

10∙ Refer the infected child to higher levels of specialized care if necessary

Treatment of HIV/AIDS in Children (ARV therapy)

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Clinical Manifestation of HIV / AIDS in Children

On history taking

Unusually frequent and severe occurrences of common childhood bacterial infections, such as otitis media, sinusitis, and pneumonia
Recurrent fungal infections, such as candidiasis (thrush), that do not respond to standard antifungal agents: Suggests lymphocytic dysfunction
Recurrent or unusually severe viral infections, such as recurrent or disseminated herpes simplex or zoster infection or cytomegalovirus (CMV) retinitis; seen with moderate to severe cellular immune deficiency
Growth failure
Failure to thrive
Wasting
Failure to attain typical milestones: Suggests a developmental delay; such delays, particularly impairment in the development of expressive language, may indicate HIV encephalopathy ∙ Behavioral abnormalities (in older children), such as loss of concentration and memory, may also indicate HIV encephalopathy

During Physical examination inclusive of investigations

Candidiasis: Most common oral and mucocutaneous presentation of HIV infection ∙ Thrush in the oral cavity and posterior pharynx: Observed in approximately 30% of HIV-infected children
Linear gingival erythema and median rhomboid glossitis
Parotid enlargement and recurrent aphthous ulcers
Hepatic infection with herpes simplex virus (HSV): May manifest as herpes labialis, gingivostomatitis, esophagitis, or chronic erosive, vesicular, and vegetating skin lesions; the involved areas of the lips, mouth, tongue, and esophagus are ulcerated
HIV dermatitis: An erythematous, papular rash; observed in about 25% of children with HIV infection
Dermatophytosis: Manifesting as an aggressive tinea capitis, corporis, versicolor, or onychomycosis ∙ Pneumocystis jiroveci (formerly P carinii) pneumonia (PCP): Most commonly manifests as cough, dyspnea, tachypnea, and fever
Lipodystrophy: Presentations include peripheral lipoatrophy, truncal lip hypertrophy, and combined versions of these presentations; a more severe presentation occurs at puberty ∙ Digital clubbing: As a result of chronic lung disease
Pitting or non-pitting edema in the extremities
Generalized cervical, axillary, or inguinal lymphadenopathy

Signs/conditions very specific to HIV infection

Pneumocystis pneumonia
Esophageal candidiasis
Extrapulmonary cryptococcosis
Invasive salmonella infection
Lymphoid interstitial pneumonitis
Herpes zoster (shingles) with multi-dermatomal involvement
Kaposi’s sarcoma
Lymphoma
Progressive multifocal encephalopathy

Signs/conditions common in HIV-infected children and uncommon in uninfected children

Severe bacterial infections, particularly if recurrent
Persistent or recurrent oral thrush
Bilateral painless parotoid enlargement
Generalized persistent non-inguinal Lymphadenopathy
Hepatosplenomegally (in non-malaria endemic areas)
Persistent and recurrent fever
Neurologic dysfunction
Herpes zoster, single dermatome
Persistent generalized dermatitis (unresponsive to treatment)

Conditions common in HIV-infected children but also common in ill uninfected children

Chronic recurrent otitis with ear discharge
Persistent or recurrent diarrhoea
Severe pneumonia
Tuberculosis
Bronchiectasis
Failure to thrive

Opportunistic Infections in Children

Common clinical conditions associated with HIV

Babies are born with an immature and immunologically naïve immune system, predisposing them to an increased frequency of bacterial infections. The immunosuppressive effect of HIV are additive to those of immature immune system and place HIV-infected infants at high risk of invasive bacterial infections. Common childhood infections and conditions are more frequent in HIV-infected children and have a higher case fatality compared to uninfected children. These infections include:
Diarrhea
Acute suppurative otitis media
Sinusitis
Failure to thrive
Immunization and cotrimoxazole prophylaxis significantly decreases the frequency of invasive bacterial infections in HIV-infected children.

Common Opportunistic Infections

Cytomegalovirus: presents with encephalitis with retinitis or neuritis
Cryptococcus: presents with fever, headache, seizures, change in mental status; focal neurological signs are uncommon
Toxoplasmosis: most common manifestations are encephalitis, mental changes, fever, headache, and mental confusion
Herpes simplex virus: is associated with fever, altered state of consciousness, personality changes, convulsions
Kaposi’s sarcoma: this presents as early as the first month of life. It is associated with human herpes virus and usually presents as generalized Lymphadenopathy, black/purple mucocutaneous lesions (skin, eye, mouth)
Bacterial pneumonia: It is the leading cause of hospital admissions and death in HIV infected children. Streptococcus pneumoniae is the most common pathogen isolated. Other organisms include: H. influenzae, staphylococcus aureus, Klebsiella.
Pneumocystis pneumonia (PCP): PCV is caused by a fungus called Pneumocystis jiroveci(formally known as pneumocystis carnii). It is a major cause of severe pneumonia and death in HIV-infected infants.
Tuberculosis: Tuberculosis and HIV-co-infection; The HIV pandemic has led to the resurgence of tuberculosis in both adults and children. Children are at increased risk of developing primary progressive tuberculosis because of the associated severe immune suppression resulting from their young age and HIV. There is a high fatality rate for children who are co-infected with tuberculosis and HIV.
Lymphoid interstitial pneumonia (LIP): LIP is common in children (occurs in about 40% of children with perinatal HIV) and usually occurs in children more than 2 years of age.
Viral pneumonitis: It develops due to a number of viruses, including respiratory syncytial virus, para-influenza virus, influenza virus, adenovirus, varicella, measles and Cytomegalovirus (CMV).

Examples of Opportunistic infections

Bacterial OIs

∙ Pneumococcal pneumonia
∙ Pulmonary tuberculosis
∙ Salmonellosis
∙ Extra-pulmonary tuberculosis

Viral OIs

∙ Herpes zoster
∙ Recurrent/disseminated viral herpes simplex

Parasitic OIs

∙ Pneumocystis cariini pneumonia
∙ Toxoplasmosis

Fungal OIs

∙ Cryptosporidium
∙ Oro-pharyngeal candida
∙ Candida Esophagitis
∙ Histoplasmosis
∙ Coccidioidomycosis,
∙ Cryptococcal meningitis

Opportunistic cancers

∙ Invasive cervical cancer (caused by human papilloma virus)
∙ Kaposi sarcoma (caused by human herpes virus 8 HHV-8)
∙ Non Hodgkin lymphoma

Causes of opportunistic infections in HIV/AIDS children

∙ Poor adherence to treatment
∙ Presence of other diseases e.g. juvenile diabetes mellitus
∙ Delay in identification of the Infection
∙ High viral load
∙ Poor nutrition
∙ Exposure to opportunistic infectious agents
∙ Ingestion of substances contaminated with opportunistic infectious agents ∙ Missing out immunization programs
∙ Poor hygiene of the child
∙ Poor sanitation
∙ Poor ventilation

Prevention of opportunistic infections

∙ Avoidance of contact with the disease agents
∙ Proper treatment of other underlying diseases
∙ Adherence on HIV drug treatment
∙ Immunization of children against killer diseases
∙ Ensuring that children eat well cooked food and boiled water
∙ Early identification and treatment of the opportunistic diseases ∙
∙ Health education of the family and infected child about opportunistic infection

General management of opportunistic infections

Assessment of the child

⇒ History taking from the mother/caregiver and the child if he/she is verbal ∙ Physical examination

⇒ Vital observations

⇒ Head to toe examinations

⇒ Investigations e.g. blood microscopy e.t.c

Provision of treatment

No.	Type of infections	Drugs of choice
1.	Fungal infections	Anti – fungals
2.	Bacterial infections	Anti – bacterials
3.	Viral infections	Anti – virals
4.	Parasitic	Anti – protozoa
5.	Cancers	Cytotoxic drugs

WHO CLINICAL STAGING OF HIV

Staging HIV infection and disease in children

Staging is a standardized method for assessing disease stage/progression and for making treatment decision. Clinical and laboratory parameters are used to stage HIV disease.

WHO staging for HIV infection and disease in children above 10 years

Clinical Stage I:

Asymptomatic
Persistent generalized lymphadenopathy

Clinical Stage II:

Moderate weight loss (less than 10% of presumed or measured body weight)
Minor muco-cutaneous manifestations (seborrhoeic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations, angular stomatitis)
Herpes zoster within the last five years
Recurrent upper respiratory tract infections, e.g., bacterial sinusitis, tonsillitis, otitis media and pharyngitis

Clinical Stage III:

Severe weight loss (more than 10% of presumed or measured body weight)
Unexplained chronic diarrhea for more than one month
Unexplained prolonged fever, intermittent or constant, for more than one month 4. Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (current)
Severe bacterial infections such as pneumonia, pyomyositis, empyema, bacteremia or meningitis 8. Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
Unexplained anemia (<8gm/dl), neutropenia (<0.5× 109 per liter), or chronic thrombocytopenia (<50× 109 per liter)

And/or Performance Scale 3: Bed-ridden for less than 50% of the day during the last month

Clinical Stage IV:

HIV wasting syndrome – weight loss of more than 10%, and either unexplained chronic diarrhea for more than one month or chronic weakness or unexplained prolonged fever for more than one month
Pneumocystis pneumonia (PCP)
Recurrent severe bacterial pneumonia
Toxoplasmosis of the brain
Cryptosporidiosis with diarrhea for more than one month
Chronic isosporiasis
Extra-pulmonary cryptococcosis including meningitis
Cytomegalovirus infection (retinitis or infection of other organs)
Herpes simplex virus (HSV) infection, mucocutaneous for more than one month, or visceral at any site
Progressive multifocal leukoencephalopathy (PML)
Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis
Candidiasis of the oesophagus, trachea, bronchi or lungs
Atypical mycobacteriosis, disseminated
Recurrent non-typhoid salmonella septicemia
Extra-pulmonary tuberculosis
Lymphoma
Invasive cancer of the cervix
Kaposi’s sarcoma
HIV encephalopathy – disabling cognitive and/or motor dysfunction interfering with activities of daily living, progressing slowly over weeks or months, in the absence of concurrent illness or condition other than HIV infection that could account for the findings.
Atypical disseminated leishmaniasis
Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy And/or Performance Scale 4: Bed-ridden for more than 50% of the day during the last month

WHO staging for HIV infection and disease in infants and children

Clinical Stage I:

Asymptomatic
Persistent generalized lymphadenopathy

Clinical Stage II:

Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Linear gingival erythema
Herpes zoster
Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis)
Fungal nail infections

Clinical Stage III:

Unexplained moderate malnutrition not adequately responding to standard therapy
Unexplained persistent diarrhea (14 days or more)
Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month)
Persistent oral candidiasis (after first six weeks of life)
Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis/periodontitis
Lymph node Tuberculosis
Pulmonary Tuberculosis
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anaemia (<8.0 g/dl), neutropenia (<0.5 x 109/L3) or chronic thrombocytopenia (<50 x 109/ L3)

Clinical Stage IV:

Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
Pneumocystis pneumonia (PCP)
Severe recurrent bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)
Chronic herpes simplex infection; (oro labial or cutaneous of more than one month’s duration, or visceral at any
site)
Extra-pulmonary Tuberculosis
Kaposi’s sarcoma
Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
Toxoplasmosis of the brain (after the neonatal period)
HIV encephalopathy
Cytomegalovirus (CMV) infection (retinitis or infection of other organs) with onset at age over one month
Extra-pulmonary cryptococcosis (including meningitis)
Disseminated endemic mycosis (extra-pulmonary histoplasmosis, coccidiomycosis)
Chronic cryptosporidiosis (with diarrhea )
Chronic isosporiasis
Disseminated non-tuberculous mycobacteria infection
Cerebral or B-cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy
HIV-associated cardiomyopathy or nephropathy

Diagnostic Measures

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Clinical Manifestation of HIV / AIDS in Children Read More »

HIV & AIDS in Children

HIV (Human Immunodeficiency Virus) is a unique type of virus (i.e. a retrovirus) that invades the T- helper cells (CD4 cells) in the body of the host (defense mechanism of a person).

AIDS (Acquired Immunodeficiency Syndrome) is a disease of the human immune system caused by infection with human immunodeficiency virus. In children it is acquired perinatally or by vertical -maternal-infant transmission.

HIV is the virus that causes AIDS

Introduction to HIV & AIDS in Children.

Considerable progress has been made towards eliminating human immunodeficiency virus (HIV) among children; however, the global burden of pediatric HIV and acquired immune deficiency syndrome (AIDS) remains a challenge for health care workers around the world, particularly in developing countries.

Epidemiology

Each day, some 1500 children under 15 years of age become infected with HIV, an estimated 90% of whom live in sub-Sahara-Africa. In 2005, there were 2.3 million (1.7–3.5 million) children living with HIV worldwide, most of whom acquired the virus in utero, during birth or while being breastfed, ways of contracting HIV that can be prevented.

For many children infected with HIV, the chances of survival are slim. Worldwide, AIDS now accounts for 3% of deaths in children under five years of age—and 6% of those in sub-Saharan Africa, where AIDS has become one of the major killers of young children.

One in seven people dying of HIV-related illness worldwide is a child under 15 years old. This is due largely to the failure to introduce programs for preventing mother-to-child transmission of HIV on the scale needed. Without HIV care, including antiretroviral therapy, the progression of HIV infection in children is particularly aggressive. In 2005, an estimated 380 000 (290 000–500 000) children died of HIV-related causes. It is likely that one half of them did not live past their second birthday.

Mode of Transmission

There are several potential modes of transmission of HIV to children:

Mother to child transmission: more than 95% of HIV-infected infants in Africa acquire HIV from their mothers during pregnancy, at the time of delivery, or potentially through breast feeding. Without any intervention, between 30 to 40% of breast-feeding HIV positive women transmit HIV to their newborns.
Sexual transmission among adolescents
Sexual abuse of children
Transfusion of infected blood or blood products
Unsterile injection procedures, and scarification

Risk factors for mother to child HIV-transmission

The risk factors associated with maternal to child transmission include the following:

Maternal factors

Women with high viral load are more likely to transmit HIV to their newborns
Women with severe immunosuppression (CD4 count below 200) and those with advanced disease.
Maternal micronutrient deficiencies increase the risk of MTCT of HIV significantly
Prolonged rupture of membranes, chorioamnionitis, and STIs
During breastfeeding, cracked nipples and breast abscesses
HIV-1 is more readily transmitted from an HIV-infected woman to her infant than is HIV-2.

Infant factors

Prematurity
Breastfeeding
Oral thrush and oral ulcers
Invasive fetal monitoring
Birth order (first twin) in twin pregnancy

Pathogenesis

The human body is made out of millions of different cells. Each body cell often makes new cell parts in order to stay alive and to reproduce.
Viruses hide their own material inside the cells of the body, and then, when the body cells try to make new parts, they accidentally make new viruses as well.
HIV mostly enters cells of the immune system.
Although HIV infects a variety of cells, its main target is the T4-lymphocyte (CD4): a kind of white blood cell that is responsible for warning the immune system that there are invaders (diseases) in the body.
Once HIV binds to a cell structure, it hides its material inside the cell. This turns the cell into a sort of HIV factory.
HIV enters the CD4 cell VIRAL GP120- (fusion and entry)
Now, HIV enters the centre of the cell. To do this, it needs to make some important changes in the way it looks so that it will not be ‘recognized’ by the cell. HIV has a special substance to make these changes in its structure.- (reverse transcription)
HIV is present in the centre of the cell, but in a different shape- (integration to genome).
The centre of the cell starts to make new parts of HIV instead of making new parts for the body’s defence. (transcription and translation).
Before leaving the cell, the new parts of HIV need to be put together, just like parts of a car need to be put together in the factory before they can leave the factory to be sold. HIV has a special substance that helps to put the different parts together to form a new HIV before it leaves the cell- budding
HIV attacks many CD4 cells. The infected CD4 cells will first produce many new copies of the virus, and then die. The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and then die. This goes on and on: more and more CD4 cells are destroyed, more and more new copies of HIV are made, and new CD4 cells get infected.

Steps / Phases in HIV entry

CD4 & chemokine receptors are needed for HIV entry therefore the following are the phases

Viral Entry: Binding of gp 120, CD4 and chemokine receptors results in changes in gp41 and fusion of the virion and cell surface membrane. Strands of viral RNA are released into the cell cytoplasm
Reverse Transcription: In nature DNA produces RNA, but retroviruses can convert single stranded RNA into double stranded DNA using an enzyme called reverse transcriptase
Integration: Viral DNA integrates into the host chromosome DNA to form a provirus
Transcription: back to RNA. In activated lymphocytes, transcription of viral DNA results in production of multiple copies of viral RNA. HIV RNA has 9 genes which code for the production of structural proteins like the viral envelope and core, in addition to reverse transcriptase, integrase,
and protease
Translation: RNA to protein
Viral protease; Viral protease cleaves [cuts] the polypeptide chain into enzyme components like integrase and reverse transcriptase which help produce new virions
Assembly and budding: Viral RNA and proteins are packaged and released from lymphocyte surface

How HIV attacks the body.

The CD4 (white blood cell), is a friend of the body. Problems like cough, diarrhoea try to attack the body, but the CD4 fights them to defend the body, its friend.
Now, HIV enters and starts to attack the CD4. The CD4 notices it cannot defend itself against HIV. Soon, CD4 loses its fight against HIV. The body remains without defence.

The body is all alone, without defence, so all kinds of problems, like cough and diarrhoea take advantage and start to attack the body. In the end, the body is so weak that all diseases can attack without difficulty.

Clinical Manifestation of HIV / AIDS in Children

HIV & AIDS in Children Read More »

Bipolar Affective Disorder

Bipolar Affective Disorder is formerly called manic-depressive illness (MDI). B.A.D is severe and persistent condition that causes serious lifelong struggle and challenge.

Bipolar affective disorder is a mental health condition characterized by mood swings, from deep and prolonged low mood (profound depression) to extreme euphoria (mania), with intervening normal periods.

Episodes of mood swings may occur rarely or multiple times a year. While some people will experience some emotional symptoms between episodes, some may not experience any.

They are of three kinds i.e.

Mixed bipolar disorder that is both manic and depressive episodes intermixed
Manic bipolar disorder; here there is predominant elation of mood, irritability, excessive motor activity and evident psychotic features
Depressed bipolar disorder; symptoms are characteristic of major depression with a history of at least one manic episode.

Symptoms of bipolar affective disorder

Symptoms of bipolar vary from person to person and from time to time depending on the phase the patient is in.

Manic episode

Manic episodes have at least 1 week of profound mood disturbance characterized by elation and irritability at least 3 of the following;

grandiosity
Increased energy, activity (boundless energy)
Exaggerated sense of well-being and self-confidence (euphoria)
Decreased need for sleep
Unusual talkativeness
Racing thoughts or flight of ideas
Distractibility
Poor decision making for example taking sexual risks or making foolish investments

Hypomanic episode

This is characterized by elated or irritable mood of at least 4 consecutive days duration. The diagnosis of hypomania requires at least 3 of the above symptoms the difference being that here the symptoms are not severe enough to cause marked impairment in social or occupational functioning

Depressive episode

In a major depressive episode, for the same 2 weeks a person may experience 5 or more of these symptoms with at least one of the symptoms being either depressed mood or loss of pleasure or interest.

Depressed mood, such as feeling sad, hopeless, tearfulness and irritability in children and teens
Marked loss of interest or feeling of no pleasure in almost all activities
Significant weight loss when not dieting
Psychomotor retardation or agitation
Either insomnia or sleeping too much (hypersomnia)
Either restlessness or slowed behaviour
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Decreased activity to think or concentrate
Thinking about, planning or attempting suicide
Melancholia; this refers to depression not triggered by a stressor

Management of bipolar affective disorder

The treatment of bipolar affective disorder is directly related to the phase of episode (i.e. depression or mania and the severity of that phase.

MANIA

Mania is condition characterized by excessive or extreme elation of mood and increased activity.

It is a state of mind manifesting with cheerfulness, euphoria, and rapidly changes to irritability.

Types of mania

Hypomania: This is a mild form of mania

Acute mania: Acute, severe and heavy form of mania

Delirious mania: Excitation characterized by confusion mainly found in organic psychoses.

Chronic mania: Mania that has occurred in the patient, it could be simple form but has failed to respond to various forms of treatment. It usually occurs in people 40 years and above.

CAUSES OF MANIA

Genetic factors; mania is said to run in families
Increase in levels of noradrenaline metabolites
Imbalances in serotonin levels in blood
Increase in dopamine levels
Cyclothymic type of personality (mood swings) plays a big role in the causation of manic illness occurrence.
Body physic;
Psychosocial factors like those resulting from stresses e.g. Divorce, bereavement etc.

Clinical features of mania

Elation of mood
Great deals of energy (boundless energy)
Usually restless and over active
Poor concentration and easily destructed by other activities
Patients have high appetite for food and drinks but usually have no time to eat since they lack concentration
Increased urge for sex (high libido)
Excessive involvement in pleasurable activities e.g. excessive spending habits
Dressing is usually inappropriate with bright colours that do not match, excessive make-up and jewelery.
Delusions of grandeur are more pronounced
Over talkativeness and pressure of speech in acute forms of mania
Racing thoughts i.e. accelerated thinking (the speech is very fast and continuous)
Insight is lost
Sleep is disturbed and a patient may have total insomnia
Auditory hallucinations are very common
Ideas of reference are very common (when the patient feels that people are conversing about him)

Diagnosis of mania

The following features are diagnostic of mania;

Abnormally elevated mood and irritability
Grandiosity (over rating one’s self)
Boundless energy
Over activity
Over talkativeness
Racing of thoughts
Poor concentration and easily destructed.

Management

Hypomanic can be managed at home if there is someone to assist them take their medications

Hospitalization: If the patient is too excited, is a public nonsense, not taking care of himself e.t.c. then admission to mental health hospital is very essential.

Establishment of therapeutic relationship is very important because, it`s the key to the nursing care.
If the patient is very excited, restless and unable to be calm down by the verbal instruction of the care team, a tranquilizer or a sedative such as chlorpromazine 100-200mg or Haldol 5-10mg by injection are administered
Reduce the dosage and frequency as the symptom subsides.
Short simple direct answers should be given when a patient asks questions.
Ensure a low stimuli of the patient`s environment.
Remove all the dangerous particles like iron bars, sharp instruments, easily portable stone etc that the patient can use to harm himself and others.
Supervise and maintain personal hygiene.
Special attention must be given to patient’s diet because a patient is usually too busy to eat because of hyperactivity and restlessness. diet rich in carbohydrates, proteins with a lot of fluids is recommended.
Observe the patient behaviors, toilet habits, eating habits, steep etc

DRUG TREATMENT

To control the manic symptoms antipsychotic like Haldol or chlorpromazine can be used.

CPZ (chlorpromazine) 100-1200mg in divided doses which may be reduced when the patient improves

Thioridazine 100-600mg in divide doses (it can also help to lower the patient libido)
Haloperidol: 5-15mg nocte for not more than to work
Lithium carbonates: 250-550mg doses (it is the drug of of choice in manic patients)
Benzelhexol (artane)

Other drug used in manic illness in

Carbamazepine: 100-400mg in divided doses
Sodium volporate: 100-1500mg in divided doses (but are usually given given in carbonates).

ELECTRO COMVULSIVE THERAPY

This is very good especially in manic excitement. 1 or 2 shocks a week for 6-9 weeks. ECT is very effective when given in combination with drugs.

OCCUPATIONAL THERAPY

Occupational therapy is very important for recovering patient and the type of occupation varies from individual patient to another.
Psychotherapy to the family is very helpful
Resettlement and good follow up system should be put in place for individual patient.

Nursing care of manic patients

Diet; special attention has to be given to patients diet because he is usually too busy to eat and hence may lose weight and also dehydration may occur.
Meals and fluids have to be given under supervision and extra nourishment may be required to compensate for extra activity.
Care has to be taken to ensure that the patient dresses well
Supervision and directions to maintain personal hygiene like bathing, oral hygiene is essential.
one nurse has to be assigned to the over active patient so as to improve his confidence in her
Maintain a low level of stimuli to the patient environment i.e. Factors like noise and bright colours should be avoided in the ward otherwise the ward should be quiet and pleasant.
observe patients behaviour frequently and report any changes
remove any dangerous objects from the patients environment that can be used to harm self or others during times of agitation
Injuries attained by the patient because of his hyperactivity have to be attended to.

Prognosis

If well treated, most episodes resolve within three months and rarely last for more than 6months
There is risk of reoccurrence if the disorder begins before 30years of age
Studies have revealed that 10-20% of the sufferers have had 3 episodes of depression before developing mania
The prognosis of mania is far better than that of schizophrenia

Bipolar Affective Disorder Read More »

Mood Disorders in Children and Adolescents

Mood Disorders In Children and Adolescents

Mood disorders are chronic, often debilitating illnesses that affect people of all ages.

Mental health problems ranging from depression to bipolar disorder are known as mood disorders, or affective disorders. In any of these disorders, a serious change in mood shapes the child’s emotional state. Unlike a normal bad mood a child feels occasionally, a mood disorder involves thoughts and feelings that are intense, difficult to manage, and persistent. A mood disorder is a real medical condition, not something a child will likely just “get over” on his own.

Today, clinicians and researchers believe that mood disorders in children remain one of the most under diagnosed health problems. Mood disorders that go undiagnosed can put children at risk for other conditions, like disruptive behavior and substance use disorders, that remain after the mood disorder is treated. Children and teens with a mood disorder don’t always show the same symptoms as adults. So it can be difficult for parents to recognize a problem in their child, especially since he or she may not easily express his or her thoughts or feelings.

The most common mood disorders in children and adolescents include:

Major depression. A depressed or irritable mood, lasting at least two weeks.
Persistent depressive disorder (dysthymia). A chronic, low-grade, depressed or irritable mood for at least 1 year.
Bipolar disorder. Periods of persistently elevated mood followed by periods of depressed or flat emotional response.
Disruptive mood dysregulation disorder. A persistent irritability and extreme inability to control behavior.
Premenstrual dysphoric disorder. This includes depressive symptoms, irritability, and tension before menstruation.
Mood disorder due to a general medical condition. Many medical illnesses, including cancer, injuries, and chronic medical illnesses, can trigger symptoms of depression.
Substance-induced mood disorder. Symptoms of depression due to drug use, the effects of a medication, or exposure to toxins.

Girls are at least twice as likely as boys to develop depression. Boys and girls are equally likely to develop bipolar disorder and obsessive-compulsive disorder.

Causes

The causes of mood disorders are not well understood. however the following can be attributed to;

Imbalances in brain chemicals.
Environmental factors, such as unexpected life events and/or chronic stress, can also contribute to a mood disorder.
Mood disorders often run in families, so there is a genetic component, too. Children who have relatives with depression are at increased risk for depression. In addition, a family history of bipolar disorder may predispose a child to have bipolar disorder or other mood disorder.
Sometimes, extreme stress or a life event can “turn on” a gene, causing the disorder to develop. This can happen especially with depression.

Signs and Symptoms

Children show symptoms differently, according to their age and biological makeup. Symptoms also vary according to the type of mood disorder. Overall signs of a mood disorder may include:

Sad, depressed, irritable, angry, or elevated mood that appears more intense than the child usually feels, lasts for a longer period of time, or occurs more frequently
Trouble with family, including difficult behavior
Lack of motivation or pleasure in previously enjoyed activities
Changes in sleep or eating patterns or weight
Frequent physical complaints, such as headaches, stomachaches, or fatigue
Loss of energy or fatigue
Difficulty achieving in school
Worthlessness, guilt, or low self-esteem
Severe recurrent temper outbursts
Increased energy or bursts of energy with racing thoughts or fast speech
Rebellious or high risk behavior
Running away or threats of running away from home
Difficulty with friends and peers
Expressions of suicidal thoughts, which should be evaluated immediately

Diagnosis

An accurate diagnosis of the mood disorder, as well as any other conditions, is a crucial first step in managing the disorder effectively. At the Hospital, a specialist performs a comprehensive evaluation. The evaluation may assess:

child’s overall health and medical history
child’s symptoms
child’s behavior at home, at school, and with peers
Environmental factors that might be stressors in your child’s life
Input from teachers or guidance counselor about issues at school
child’s past experiences with specific medications or therapies
opinion or preference for treatment options

Treatment

Mood disorders can be treated with evidence-based treatments, especially with early recognition of the problem. Treatment can help manage the episode, reduce the severity of symptoms, and help to prevent future episodes. It can also enhance the child’s normal growth and development and improve his or her quality of life and relationships.

Individual therapy

identify key problems in the child’s life and help the child learn how to manage these stressors.
Also use a variety of techniques to help the child manage the symptoms of the mood disorder, including
- Cognitive-behavior. This approach involves changing problematic thoughts, feelings, and behaviors that your child may be experiencing.
- Interpersonal therapy. This technique focuses on building social skills and helping children with difficult relationships in their lives.
Family therapy

Families play a vital supportive role in any mood disorder. Families, including parents or guardians, can learn methods to help their child manage mood and behavior problems. The specialist may also explore potential stressors in a child’s life and patterns of interaction within the family. A consultation with the child’s teachers or guidance counselor may also be advised.

Medications

A variety of medications are very effective in treating mood disorders by altering the brain chemicals involved. Depending on the mood disorder and the child’s symptoms, medications may reduce the severity or frequency of symptoms, decrease problematic behaviors, improve functioning, and prevent future episodes.

Outlook

Many children who receive early and adequate treatment for their mood disorder may improve significantly and keep their condition managed with ongoing intervention or support . If the episodes recur, they can usually be managed with therapeutic support, including medications, therapy, and additional resources.

Follow-up Care

Depending on the child’s personalized treatment plan, the child and family may continue to meet with the specialist for a number of weeks or months. The focus of individual and family therapy may change over time, depending on the child’s age, progress, and needs. Medication needs may also change over time depending on a number of factors.

SPECIFIC MANAGEMENT OF MOOD DISORDERS.

Assessment 🕵️‍♀️
- Conduct thorough assessments to understand the child’s mood disorder, including emotional triggers and symptoms.
Supportive Environment 🌈
- Create a safe and nurturing environment to promote emotional well-being.
Therapeutic Communication 🗣️
- Utilize effective communication techniques to build trust and encourage expression of feelings.
Medication Management 💊
- Administer prescribed medications as directed, and monitor for any side effects or changes in mood.
Psychotherapy 🧘‍♀️
- Encourage participation in individual or group therapy sessions to address underlying issues.
Education 📚
- Provide education to both the child and their family about the mood disorder, coping strategies, and treatment options.
Behavioral Interventions 🧩
- Implement behavior modification techniques to manage disruptive behaviors and promote positive coping mechanisms.
Emotion Regulation 🧘‍♂️
- Teach the child emotional regulation skills, such as mindfulness and relaxation techniques.
Family Involvement 👪
- Engage the family in therapy and support, as their understanding and involvement are crucial.
Safety Monitoring 🚸
- Continuously monitor the child’s safety to prevent self-harm or harm to others, especially in severe cases.

BIPOLAR AFFECTIVE DISORDER click here

Mood Disorders in Children and Adolescents Read More »

Attention-Deficit/Hyperactivity Disorder

Attention-deficit hyperactivity disorder

Attention deficit hyperactivity disorder is the most commonly diagnosed mental disorder of children and teens and which can also continue to adulthood. Children with ADHD may be hyperactive and unable to control their impulses or they may have trouble paying attention

Attention deficit hyperactivity disorder (ADHD) is a brain disorder marked by an on-going pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning of development.

Inattention means a person wanders off task, lacks persistence, has difficulty sustaining focus and is disorganized and these problems are not due to defiance or lack of comprehension.

Hyperactivity means a person seems to move about constantly, including in situations in which it is not appropriate or excessively fidgets, taps, or talks.

Impulsivity means a person makes hasty actions that occur in the moment without first thinking about them and that may have high potential for harm or a desire for immediate rewards or inability to delay gratification. An impulsive person may be socially intrusive and excessively interrupt others to make important decisions without considering the long-term consequences.

This disorder is characterized by severe disruption of attention along with over activity more frequent and severe than is typical of children at a similar level of development. ADHD is thought to result from brain damage during birth. A child with ADHD cannot sit still or remain at one place for any length of time, is always on the go, fears no dangers, climbing and playing dangerously with house hold objects. The prevalence is much common in boys than girls

Aetiology

Biological influences

genetics; ADHD tends to run in families
biochemical theory; a deficit of dopamine and norepinephrine neurotransmitters has been attributed to cause over activity as seen in ADHD

Pre, Peri and postnatal factors

prenatal toxic exposure
prematurity
fetal distress
precipitated or prolonged labour
perinatal asphyxia
low Apgar scores
postnatal infections
CNS abnormalities resulting from trauma

Environmental influences

lead poisoning
food additives, colouring, preservatives and sugars

Psychosocial factors

prolonged emotional deprivation
stressful psychic events
disruption of family equilibrium

Risk factors

drug exposure in utero
birth complications
low birth weight
lead poisoning

Clinical features

sensitive to stimuli, easily upset by light, noises or environmental changes
more commonly active an sleeps little
short attention life span
failure to finish tasks
impulsivity
memory and thinking difficulties
specific learning disabilities

In school

answers only the first two questions and often blurts out answers before questions have been completed
unable to wait to be called on in school and may respond before everyone else
has difficulty awaiting in games or group situations
often loses things necessary for tasks or activities at school

Home

explosive or irritable
emotionally labile and easily set off to laughter or tears
unpredictable mood
impulsiveness and inability to delay gratification
often talks excessively
often engages in physically dangerous activities without considering possible consequences

Symptoms can also be grouped as follows;

Inattention symptoms

Overlook or miss details or make careless mistakes in schoolwork
Have problems sustaining attention in tasks or play including conversations, lectures or lengthy reading
Not seem to listen when spoken to directly
Not follow instructions and fail to finish school work or duties on work or start tasks but quickly lose focus and get easily side-tracked
Have problems organizing tasks and activities, such as what to do in sequence, keeping materials and belongings in order, having messy work and poor time management and failing to meet deadlines
Avoid or dislike tasks that require sustained mental effort, such as school work or homework.
Loose things necessary for tasks or activities such as school supplies, pencils, books, tools, eyeglasses, paperwork etc.
Be easily distracted by unrelated thoughts or stimuli
Be forgetful in daily activities like keeping appointments.

Hyperactivity-impulsivity symptoms

Leave seats in situations when staying seated is expected such as in classroom
Run or dash around or climb in situations where it is inappropriate or restless in teens
Be unable to play or engage in hobbies quietly
Be constantly in motion or ‘on the go’ or act if ‘driven by a motor’
Talking nonstop
Blurt out an answer before question has been completed, finish other peoples sentences or speak without waiting for a turn in conversation
Have trouble waiting for his or her turn
Interrupt or intrude on others, for example conversations, games or activities
Constant fidgeting
Acting without thinking
Little or no sense of danger

MANAGEMENT

Pharmacotherapy;

Medication do not offer permanent cure for ADH but may help someone with the condition to concentrate better, be less impulsive, fell calmer and learn to practice new skills. Drugs licensed for treatment of ADHD include;

Methylphenidate one tablet once a day
Lisdexamfetamine once capsule once a day
Dexamfetamine one tablet once or twice a day
Atomoxetine one capsule once or twice a day
Guanfacine one tablet once a day

tricyclic antidepressants
Antipsychotics
serotonin specific reuptake inhibitors

Psychological therapies

Psychotherapy especially behavioural therapy is very essential as it aims at a child changing their own behaviour. It might involve practical assistance such as help organizing tasks or completing schoolwork or working through emotionally difficult events
Cognitive behavioural therapy; here a therapist tries to change how a child thinks about the situation and in turn would change the behaviour
social skill training
family therapy

Nursing interventions

Children with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed. For school age children, frustration, blame and anger may hinder recovery in other wards children need special help to overcome negative feeling and to develop new skills and attitudes.

Social skills training; this will help the child learn how to behave in social situations by learning how their behaviours affect others
Parenting skills training (behavioural parent management training) this teaches parents the skills to encourage and reward positive behaviours in their children. It helps parents learn how to use a system of rewards and consequences to change a child’s behaviour
Stress management techniques, these can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behaviour
Support groups; these help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustration and successes to exchange information about recommended specialists and strategies and to talk with experts
Diet; sugar, food colourings and additives as well as caffeine should be excluded in the patients diet as they aggravate hyperactivity

Help the child with ADHD to stay organised and stay organised by;

Keeping a routine and a schedule. Keep the same routine every day from wake-up time to bedtime. Include times of homework, outdoor play and indoor activities. Write all changes on the schedule in advance as possible
Organizing everyday items; have a place for everything and keep everything in its place. This includes clothing, backpacks and toys
Using homework and notebook organizers. Stress to the child the importance of writing down assignments and bringing home necessary books
Being clear and consistent. Children with ADHD need consistent rules they can understand and follow
Giving praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behaviour and praise it.
Develop a trusting relationship with the child that conveys acceptance of the child separate from unacceptable behaviour
Ensure patient has a safe environment free from dangerous objects that can injure him due to random hyperactive movements
Keep the child in an environment that is free from distractions to help him comply on given tasks
Ensure child’s attention by calling his name and maintain an eye contact before giving instructions
Ask patient to repeat instructions before beginning the task
establish goals that allow the patient to complete part of the task, rewarding each step completion with a break for physical activity
Provide assistance on one-to-one basis beginning with simple concrete instructions
Gradually decrease the amount of assistance given to task performance while assuring patient that assistance is available if still needed
Offer recognition for successful attempts and positive reinforcement for attempts made
Provide quiet environment, self-contained classrooms an small group activities
Help the patient to learn how to take his turn, wait in line and follow rules
Provide information an materials related to the child’s disorder and effective parenting techniques
Explain and demonstrate positive parenting techniques to parents such as being vigilant in identifying the child’s behaviour and responding positively to that behaviour
Co-ordinate overall treatment plan with schools, child and family

Attention-Deficit/Hyperactivity Disorder Read More »

Standards of Care

Standards of Care In Mental Health

Standards of Care are a means for improving the quality care for mentally ill people.

They were enunciated by the American Nurses Association (ANA) in 1973.

Development of Code of Ethics

This is very important for a psychiatric nurse as she takes up independent roles in psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy, maintains patient’s confidentiality, protects his rights and acts as patient’s advocate.

Legal Aspects in Psychiatric Nursing

The practice of psychiatric nursing is influenced by law, particularly initial concern for the rights of patients and the quality of care they receive.

The client’s right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality and Promotion of research in mental health nursing
The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.
Cost-effective nursing care. Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.
Focus of care. A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.
Record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.

STANDARDS OF MENTAL HEALTH NURSING

The purpose of Standards of Psychiatric and Mental Health Nursing practice is to fulfill the profession’s obligation to provide a means of improving the quality of care. The standards presented here are revision of the standards enunciated by the Division on Psychiatric and Mental Health Nursing Practice in 1973.

Professional Practice Standards

Standard I: Theory

The nurse applies appropriate theory that is scientifically sound as basis for decisions regarding nursing practice. Psychiatric and mental health nursing is characterized by the application of relevant theories to explain phenomena of concern to nurses and to provide a basis for intervention.

Standard II: Data Collection

The nurse continuously collects data that are comprehensive, accurate and systematic. Effective interviewing, behavioral observation, physical and mental health assessment enable the nurse to reach sound conclusions and plan appropriate interventions with the client.

Standard III: Diagnosis

The nurse utilizes nursing diagnosis and/or standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises.

Nursing logic basis for providing care rests on the recognition and identification of those actual or potential health problems that are within the scope of nursing practice.

Standard IV: Planning

The nurse develops a nursing care plan with specific goals and interventions delineating nursing actions unique to each client’s needs.

The nursing care plan is used to guide therapeutic intervention and effectively achieve the desired outcomes.

Standard V: Intervention

The nurse intervenes as guided by the nursing care plan to implement nursing actions that promote, maintain or restore physical and mental health, prevent illness and effect rehabilitation.

(a) Psychotherapeutic interventions

The nurse uses psychotherapeutic interventions to assist clients in regaining or improving their previous coping abilities and to prevent further disability.

(b) Health teaching

The nurse assists clients, families and groups to achieve satisfying and productive patterns of living through health teaching.

The nurse uses the activities of daily living in a goal directed way to foster adequate self-care and physical and mental well-being of clients.

(d) Somatic therapies

The nurse uses knowledge of somatic therapies and applies related clinical skills in working with clients.

(e) Therapeutic environment

The nurse provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers.

Standard VI: Evaluation

The nurse evaluates client responses to nursing actions in order to revise the database, nursing diagnosis and nursing care plan.

Professional Performance Standards

Standard VII: Peer Review.

The nurse participates in peer review and other means of evaluation to assure quality of nursing care provided for clients.

Standard VIII: Interdisciplinary Collaboration

The nurse collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities.

Standard IX: Utilization of Community Health Systems

The nurse participates with other members of the community in assessing, planning, implementing and evaluating mental health services and community systems that include the promotion of the brand continuum of primary, secondary and tertiary prevention of mental illness.

Standard X: Research

The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.

Standards of Care Read More »

Law and Mental Illness

Law has relevance in nearly all aspects of nursing practice, but in no other area of nursing is the law more intimately involved than in psychiatric nursing.

This is because psychiatric clients may;

be placed on treatment against their own will
pose a risk to them selves
have been charged to have committed crime while legally insane
be un able or unwilling to consent to treatment
be incapable of fully understanding medical risks
require constant restraints for their safety or others
make threats to others
under go forensic evaluations that require nurses to testify in court

Forensic psychiatry

Forensic psychiatry is a branch of psychiatric nursing that deals with disorders of mind and their relationship with the legal principles.

It is also concerned with the assessment, investigations, diagnosis and treatment of mental disorders among three broad categories of individuals i.e.;

individuals who have are alleged to have committed an offence and face prosecution
convicted prisoners who develop mental illness in the course of serving their sentence
individuals who have not committed an offence but are at risk because of their mental capacity

Under existing mental health legislation in Uganda, its not expected that the primary health care provider will provide this service. its however advised that a PHC provider knows something about prisoners’ mental health needs for the purpose of early and appropriate referrals to centres where a psychiatrist or other mental health professionals are available.

The basic forensic psychiatry includes;

crime and psychiatric disorders
criminal responsibility
civil responsibility
laws relating to psychiatric disorders
admission procedures of patients in psychiatric hospital
civil rights of mentally ill
psychiatrists and court

Crime and psychiatric disorders

There is a close association between crime and psychiatric disorders like schizophrenia, affective disorders, epilepsy, drug dependency, personality disorders etc.

Mentally ill people may commit crime because;

they do not understand the implication of their behaviour
due to delusions and hallucinations
abnormal mental states like confusion or excitements
drug related violence

Instances when an individual facing prosecution may come to attention of a psychiatrist

when police notices signs of mental disorder in individual under their custody
when the judge observes signs of mental disorder
when relatives raise issue of mental disorder
when prisoner reports history of treatment for psychiatric disorder
when suspect pleads insane during court proceedings

Under any of the above, the magistrate may order assessment and observation of an individual to ascertain;

whether the individual is mentally disordered
the individual’s ability to stand trial if mentally disordered
whether the accused is criminally responsible for the offence he is charged with

Responsibilities of a psychiatrist in order to find answers for the above questions

hospitalize the accused for the purpose of observations and possible treatment or attend to matter as an out- patient case
take a full psychiatric history including history of previous episodes of illness and treatment
order an observation of patient by other nursing staff on dairy basis
conduct laboratory, psychological and social investigations
make a report to the magistrate who will then decide on the best course of action on the basis of a psychiatric report

Criminal responsibility

Criminal responsibility is a legal concept which refers to the extent to which an individual can be held liable for his or her offence.

According to section 84 of the Indian penal code act of 1860, “Nothing is an offence which is done by a person who, at a time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of act, or that he is doing what is either wrong or contrary to the law”.

A clinical test of responsibility may be used to determine whether an individual is responsible for an offence or not.

Criteria for criminal responsibility

Criteria for Criminal Responsibility[CCR]	SCORE
1. offence required careful planning
2. offence was unrelated to symptoms of mental disorder
3. identifiable motive for the crime was not a product of mental disorder
4. mental capacity at a time of crime was unimpaired or did not impair rational judgement
5. amnesia if present is incongruent with relevant key features of crime and mental state

Score each item 1 for a Yes response and 0 for No response. The maximum score is 5. A score of 3 and more indicates that the individual is probably responsible for an alleged crime.

Other criteria used to determine criminal responsibility

M’Naghten’s rule

This states that the individual at a time of the crime did not know the nature and quality of the act and if he did know what he was doing, he did not comprehend it to be wrong.

The Irresistible impulse act

According to this rule, a person may have known an act was illegal but as a result of mental impairment lost control of their actions.

The Durham test or Product rule

This states that an accused is not criminally responsible if his unlawful act was the product of mental disease or abnormality

American law institute

This states that a person is not responsible for criminal conduct if at time of such conduct, as a result of mental disease or defect he lacks adequate capacity either to appreciate the criminality of his conduct or to conform his conduct to requirements of the law

Ability to Stand Trial

An individual will not be expected to have an ability to stand trial under the following circumstances;

mentally ill with active signs of mental disorder
lacks ability to understand court proceedings

in cases of the above, the psychiatrist may recommend that the individual receives relevant treatment for the mental disorder and after full recovery, the individual may then stand trial. However in cases of severe psychotic illness like schizophrenia, the case might be disposed.

Convicted prisoner

In case a prisoner who is serving sentence falls ill, he or she may be referred to a mental hospital under magistrates court Act for assessment, observation and treatment. Unfortunately, under existing laws, such an individual will not be excused from serving his prison sentence on ground of mental illness otherwise he will be released at the end of a prison sentence.

Civil responsibilities of mentally ill person

Management of property

In case the court ascertain that a person is of unsound mind and incapable of managing his property, a manager is appointed by court of law to take care of his property which may include selling or disposal of property to settle debts or expenses.

Marriage

As per the Hindu marriage act 1995, marriage between any two individuals one of whom was of unsound mind at a time of marriage is considered null and void in the eyes of the law. Unsoundness of mind for a continuous period can be sighted as a ground for obtaining divorce. The other party can file divorce when unsoundness continues for a period of 2 years however divorce is granted with a precondition that one has to pay maintenance charges for the mentally ill.

Testamentary capacity

Testamentary capacity of the mental ability of a person is a precondition for making a valid will. The testator must be the major, free from coercion, understanding and displaying soundness of mind.

Right to vote

A person of unsound mind cannot contest for elections or exercise the privilege of voting.

Rights of psychiatric patients

Right to wear their own clothes
right to informed consent
right to habeas corpus
right to have individual storage space for their private use or right to privacy
right to keep and use their own personal possessions
right to spend some of their money for their own expenses
right to have reasonable access to all communication media like telephones
right to see visitors
right to treatment in the least restricted setting
right to hold civil service status or enter into legal contracts e.g marriage, personal last will etc
right to refuse treatment especially ECT
right to manage and dispose of property and execute wills

Aims of management in forensic work

diagnose to form a basis for treatment and recommendations to court
make report and submit to court
rehabilitate as part of management
promote acceptance of individual in his community
resettle individual back in community
promote after care following discharge from court and hospital

Legal responsibilities of a nurse

Psychiatric nurses are confronted on daily basis with the interface of legal issues as they attempt to balance the rights of the patient with the rights of the society. Nurses and other health care providers should never in any way violate the rights of the mentally ill.

Nurses should be aware of;

All the laws in the state in which they practice so as to protect herself from liability and patient from unnecessary detention and mistreat
patients’ rights
criminal and civil responsibilities of ill patients
legal documentation

In addition to knowing the above, the nurse should also;

protect patients’ rights
keep legal records safely
maintain confidentiality of patients information
take informed consent from patients of relatives for any procedure
explain based on the level of anxiety, span of attention and level of ability to decide

Nursing Malpractice

Malpractice involves failure of professionals to provide proper and competent care that is given by members of their profession, resulting in harm to the patient.

Common areas of liability in psychiatric service

patient committing suicide
misuse of psychoactive prescription drugs
failure to obtain consent
failure to report abuse
breach of confidentiality
failure to diagnose
inadequate monitoring of patients

Steps to avoid liability in Psychiatric nursing Services

reporting information to co-workers involved in patient care
clearly and accurately maintaining records
maintaining confidentiality of patients information
practice within the scope of state laws and nurse practice act
collaborate with colleagues to determine the best course of action
use established practice standards to guide decisions and action
always put patients’ rights and welfare first
develop effective interpersonal relationship with patients and family.
document all assessment data, treatment given, any interventions and evaluation of the patients response to care accurately and thoroughly.

To successfully argue a case of malpractice against a physician or psychiatric nurse;

The Patient must prove 3 conditions;

There is an established standard of care.
The physicians breached his/her responsibility to the plaintiff.
The physicians breach of responsibility caused injury or damage to the plaintiff.

Compensatory damages are awarded to the patient and reimbursed medical expenses, lost salary or physical suffering.

Punitive damages are awarded to the patient only in order to punish the doctor or nurse for gross negligence or carelessness.

Mental Treatment Act

LEGAL DOCUMENTS AND ADMISSION OF CIVIL PATIENTS.

Civil patients are admitted under the mental treatment act which was passed in 1964 in parliament to replace the mental treatment ordnance which was passed in 1938.

REASONS FOR PASSING THE MENTAL TREATMENT ACT

To safeguard the people with unsound mind from the public and vice vasa
To authorize the mental hospitals to detain, treat, and discharge the mentally ill patients.

There are four orders under which civil patients are admitted in mental hospitals. These ;

Urgency order
Temporary detention order
Reception order
Voluntary order

URGENCY ORDER

This is provided by sec 7 of MTA. It is for quick removal of the mentally ill from the public to the mental hospital. It is signed by any of the following;

A medical practitioner who is licensed eg registered nurse, dr, pco etc
A police officer not below the level of the assistant inspector of police.
A gazzetted chief eg a RDC,

This order remains in place for a period of 10 days. If the patient has not improved, another urgency order is signed. It is not renewed. If not cancelled after 10 days the patient has the right to sue the hospital for illegal detention.

TEMPORARY DETENTION ORDER

This is section 3 of MTA

This is the standard procedure for detaining the mentally ill patients in the mental hospital. The first and important thing is the information of the lunacy.

It can be made by any one at the ward, but in practice, it is made by the ward in charge.

This order remains in place for 14 days but can be renewed for another 14 days when it expires and cannot be renewed any further.

RECEPTION ORDER

This is section 5 of MTA

If the patient does not improve after renewing of the temporary detention order, a magistrate appoints 2 medical practitioners not related to the patient to dig out patent’s information pertaining his behavior and illness.

After the magistrate has received the medical reports, and is satisfied with the reports, he sign the order. This order remains in place for a period of 1 year. If the patient does not improve within one year, it can be renewed for another year, if still the patient has not improved, the order is renewed for 3 years, and will be renewed every 3 years.

Patients under this section are said to be satisfied and nor allowed to sign a will, vote, or stand as witness in court or marry.

VOLUNTARY ORDER

This not under the MTA but is usually legally accepted.

Here the patient comes to the hospital by himself and is directed to the medical superintendent or director who examines the patient and confirms he is mentally sick or not.

The patient will promise to abide by hospital rules and regulations.

If this patient feels he wants to leave the ward, he informs the ward in charge with in 72 hrs who in turn informs the ward doctor that will also inform the medical director or superintendent.

DISCHARGE OF CIVIL PATIENTS

Role of a nurse in discharge procedure

Identify the fitness of the patient and inform the ward doctor ( psychiatrist)
Provides feed back and information about patients discharge and seek patient’s opinion.
Make sure all the paper work and forms are ready, signed and copies sent to the records.
Ensure the patient hands over all the hospital property to the ward manager.
All necessary information especially regarding medications, follow up dates, should be made clear to the patient.
The nurse must bare in mind that the patient may be having mixed minds about staying in the hospital and going back to the community. And so must help the patient to coup.
Depending on circumstances, the patient’s community should be well prepared to receive and stay with the patient.
The nurse should at least escort the patient out of the ward or hospital compound.

Civil patients are discharged under the following sections in MTA

SEC 18; FOR RECOVERED PATIENTS

After the nurse has approved the fitness she informs the ward doctor who recommends the fitness and writes to the director reply and authorizes the doctor to discharge the patient on treatment. But in case the patient is on temporary detention or reception order, the magistrate if informed who then authorizes the discharge of the patient on treatment.

SEC 19; DISCHARGE OF A PATIENT UNDER THE CARE OF THE RELATIVES

If the relatives so wishes to take their patient, they should make a statement indicating that they are going to take care of the patient at home. If the patient becomes un manageable at home with in 28 days from the day of discharge, he/she can be re admitted using the previous order. But if 28 days have expired, then a new order is signed.

No drugs shall be provided unless they pay for it because it is a discharge against medical advice.

SEC 20; DISCHARGE FOR A PAYING PATIENT.

If the relatives think that they may not be able to pay the increasing costs of medical bills, they may request the medical suppretendant to discharge the patient. If the patient is still not yet well but relatives insists on discharge, the patient is discharged on a condition that if anything happens at home, the hospital will not be counted responsible. No medication is provided on discharge unless they pay for it.

SEC 21; DISCHARGE ON TRIAL LEAVE

The director of medical services authorizes the medical sup or ward Dr to discharge the patient an a trial leave for a specified period of time usually 28 days to return to the hospital for review. If the patient exceeds the 28 days given, then the patient if he /she is to be re admitted, afresh order must be signed.

SEC 22; DISCHARGE FOR ESCAPEE PATIENTS

If the patient escapes and does not return with in28days, the if brought back, he/she should not be re admitted unless a fresh order is signed. this section caters for for the safety of the hospital and management.

SEC 23; DISCHARGE OF A PERSON OF SOUND MIND;

If the person of a sound mind is detained against his will, the magistrate examines the person together with the psychiatrist and will direct the medical supretendant or ward doctor to immediately discharge the person.

SEC 36; TRANSFER OF PATIENTS

This section has 2 sub sections,

Transfer of a patient from one hospital to another within the same country. If the patient or relatives or doctor deems it necessary to transfer the patient this section will allow the transfer.
Transfer of a patient from one country to another. This section allows the transfer of a mental patient from one hospital to another hospital in a different country.

Sec 38; TRANSFER OF A FOREIGNER BACK TO THEIR OWN COUNTRY.

This provides the mandate to transfer a foreign mental patient back to his/her own country of origin.

ADMISSION AND DISCHARGE OF A CRIMINAL MENTAL PATIENT.

These are forensic patients. They can be classified into 2.

Remand patients
Class A, B and C patient.

REMAND PATIENTS (panel code act 106)

These are accused persons charged with an offence but are suspected to be of un sound mind while undergoing court proceedings .

They are taken to the mental hospital by the magistrate for ;

Observations
Investigations
Medical report as requested by the magistrate

ADMISSION OF A REMAND PATIENT.

They are brought to the mental hospital on a warrant of commitment on remand signed by the judge or a magistrate. With affixed date or open date to re appear in court.

FIXED DATE REMAND.

This is when the date of the accused to appear in court is specified. When the date reaches, the patient is sent to court accompanied by the medical report stating whether the patient is capable or incapable of pleading. If capable then he is straight away sentenced but if incapable then he/she is brought back to the hospital as class B patient.

OPEN DATE REMAND.

This is when the date of next hearing is not indicated on the warrant of commitment and when a need arises the patient is collected on a production warrant signed by the magistrate.

CLASS A PATIENT.

These are prisoners who develop mental disorders while serving their sentences in prison

ADMISSION OF CLASS A PATIENTS

They are transferred from prison to the mental hospital on the following orders.
Temporally detention order or reception order
Warrant of commitment indicating the offence committed
Warrant slip on which the expiring of the sentence is indicated’

DISCHARGE OF CLASS A PATIENT.

If the patient recovers when the sentence has not yet expired, he/she is taken back to the prison to finish his sentence on a production warrant signed by the magistrate.

If the sentence expires when the patient is in the hospital he will be discharged directly home under sec 18 of the MTA.

If the sentence expires when the patient is in the hospital and has not shown any signs of improvement he/she is called off from the register and transferred to a civil hospital on civil orders.

CLASS B PATIENTS

These are patients admitted from the court having been incapable of making their own defense and follow the court proceedings due to insanity.

They are admitted on in a mental hospital for observations and treatment on the following orders.

Warrant of detention of the accused person incapable of making a self defense signed by the minister of justice or attorney general.
Warrant of detention of accused person incapable of making a self defense signed by the magistrate or judge pending the minister’s order.

DISCHARGE OF CLASS B PATIENT

When the patient is able to plead, a psychiatrist makes a certificate of mental fitness which is taken to the director of public prosecutions who will arrange for the hearing in court.

After pleading, if the accused is found guilty, he/she is sentenced directly. But if found not guilty, due to reasons of insanity he is sent back to the mental hospital as class C patient.

CLASS C PATIENTS.

They are admitted from the court after pleading not guilty due to reasons of insanity. They are admitted on the following orders.

Warrant of detention signed by the judge or magistrate pending minister’s order
Minister’s order with a heading ORDER OF DETENTION of a person of un sound mind not found guilty due to reasons of insanity.

DISCHARGE OF CLASS C PATIENTS.

Depending on the ministers order the patient after recovery is discharged directly home unless otherwise ordered by the minister.

Law and Mental Illness Read More »

Resuscitation

Resuscitation of a Newborn

Resuscitation is a mean of restoring life to a baby from the state of asphyxia.

It is a single intervention of birth asphyxia (Devi, Upendra, and Bard, 2017). Resuscitation is helping a baby to breath.

The first 28 days of life is called neonatal period and incontrovertibly, it is the most vulnerable and high risk time in life because of the highest mortality and morbidity that occur in this period. The day of birth is the riskiest time to a baby (Sajjad, 2012; and WHO, 2015).

APAGAR SCORE

Aims of Management.

To initiate and/or restore respiration /breathing
To prevent infection
To prevent other complications
To Prevent hypothermia

Requirements

A pair of surgical gloves
Warm baby’s clothes.
Suction device e.g bulb syringe
Ventilation bag and mask (ambu bag)
Endotracheal tube to give oxygen direct to the lungs (size 1mm for full term or 0.5mm preterm babies)
laryngoscope
Nasal gastric tube
3 Gallipots
3 Receivers
Mothers chart
Tray containing a gallipot of wet swab, syringes.
Pediatric stethoscope
Strapping
Naso prongs (oxygen catheters)

Drugs

Naloxone hydrochloride 1mg ampoule 400mg/1ml
Adrenaline (Epinephrine) 1:1000
Normal saline 0.9%
Ringers lactate
Sodium bicarbonate 4.2%
Dextrose 10%
Vitamin K
Sterile water

Bed side

Resuscitation table
Timer (clock watch)
Light source
Oxygen source
Displayed chats for steps

Principles of Management.

Temperature regulation. Ensure adequate warmth for the baby to prevent hypothermia which leads to decreased metabolic which cause additional stress to the baby.
Ensure adequate oxygenation to the baby to prevent hypoxia by administration of oxygen and monitoring oxygen perfusion. An endotracheal tube should be inserted and oxygen administered
Prevention of hypoglycemia by regular monitoring blood glucose and if risk for hypoglycemia is identified administer dextrose as per prescription.

Steps for Resuscitation

TABCs of resuscitation

STEP 1

Dry the baby, wipe the baby’s mouth with gauze and remove any wet cloth.

STEP 2

Clear the air way by;

Suck blood or mucus from mouth using a bulb syringe or mucus extractor.
Position baby’s head in a neutral position with head extended.
Place a small towel under the shoulders to maintain the position.

STEP 3

Support breathing by;

Stand at the baby`s head, apply ambu-bag and a small mask to the baby’s face ensuring that the mask covers the face and mouth to form a seal.
Give five inflation breaths (each 2-3seconds duration).
Observe response by looking at the chest movements (chest rising) or increase in the heart rate. (if chest does not rise then reapply mask, reposition baby’s head, and suction.)
Continue ventilating at a rate of 30-40 breathes for a minute.
Circulation/External Cardiac Massage
Chest compression should be performed when the heart rate is less than 100b/m and falling inspite adequate ventilation
If no heart beats are recorded after one minute, do external compressions.
Wrap your palms around the baby`s chest, placing the thumbs / first finger over the lower part of the sternum.
Chest is compressed at rate of 100–120 times 1 minute at a ratio of 3 compressions to one ventilation
Use the thumb to gently compress the chest, depressing it ½ to ¾ inch each time.
If in 20 minutes the breathing is not established. Consider intubation.
When the infant has no spontaneous breathing then continuous positive pressure ventilation (CPPV) should be started with bag and mask.
The rate of chest compressions in one minute should be 90 along with 30 PPVs, (3:1), a total of 120 events.
If the heart rate is <60, despite of effective ventilation, chest compression and two intravenous doses of adrenaline (Epinephrine), the sodium bicarbonate 4.2% solution (0.5mmol/ml) can be administered using 2–4ml / kg (1-2mmol/ml) by slow intravenous.

Adrenaline (Epinephrine)

This is indicated if the heart rate is <60, despite 1 min of effective ventilation and chest compression. An initial dose of 0.1-0.3 ml/kg of 1:10,000 solution give i.v. repeated after 3 minutes for a further two doses.

10% dextrose

(Hypoglycemia is not usually a problem) 3mls/kg i.v via the umbilical vein to correct low blood sugar of <2.5mmol/L
Volume replacement
On rare occasions, bradycardia will not respond to volume expansion and bradycardia that does not respond to chest compressions or drugs is suggestive of hypovolemia–0.9% normal saline 10 ml /kg initially via the umbilical vein.

Naloxone hydrochloride

This is not an emergency drug parse it is a powerful anti-opioid drug used to reverse the effects of maternal narcotic drugs given towards the end of first stage of labour (Preceding 3hours.)
Dose 0.1–0.2 mg per kilogram body weight intramuscular.

Calcium gluconate

A dose of 100mg kg body weight and 150 adrenaline 0.1-0.5mg/kg 1 min given for severe bradycardia or cardiopulmonary arrest
Vitamin K–given prophylaxis against bleeding disorder.

Drugs

If there is no heart beat after 1 minute of breathing for the baby:
Inject 0.5 mls of 1;10,000 adrenaline solution intravenously or through the umbilical vein. Give 1 to 2 mls per kilogram body weight of 25% dextrose solution intravenously.
Continue to monitor response to resuscitation by using APGAR score.
- If the baby responds to resuscitation keep the baby warm and transfer to the special unit (NICU).
- If baby is breathing well, keep reassuring the mother
- If baby is breathing well, breast feeding should be encouraged. If no response discontinue resuscitation.

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