Pneumocystis Prophylaxis in Children: New Guidelines

Because the immune systems of children and infants are very different from those of adults, HIV infection often manifests itself uniquely in these populations. Therefore, standard treatment and prophylaxis guidelines in adults often have little relevance for infants and children. Clinicians and parents of HIV-infected children know that these children develop pneumocystis long before their T-helper counts have declined to the usual adult threshold of 200 to 300. However, almost no data exist on T-helper counts in healthy, non-HIV-infected infants and children, let alone in those with HIV infection.

A working group convened at the National Pediatric HIV Research Center at Children's Hospital in New Jersey has reviewed a series of studies of the natural history, treatment, and prevention of pneumocystis in infants and children. Their recommendations for pneumocystis prophylaxis are being published by the U. S. Centers for Disease Control in the March 15 Morbidity and Mortality Weekly Report (MMWR). The full text will be reprinted in the Journal of the American Medical Association (JAMA) on April 3. Copies can be obtained from the National AIDS Information Clearinghouse by calling 800/458-5231 after about mid-April.

Pneumocystis is a common opportunistic infection in infants with HIV. Ninety percent of young children with pneumocystis have had T-helper counts below 1500. Infants without HIV infection may have normal T-helper counts around 3,000 and as high as 5,000 -- far higher than adult values; as they grow older, the counts decline to adult values. In contrast, the T-helper percentage values are comparable between children and adults. The new recommendations take these differences into account.

Although these recommendations are a vital step toward improving the standards of health care available to infants and children, advocates for children with HIV have noted that the AIDS Clinical Trials Group (ACTG), the government-sponsored clinical trials system, is conducting little research on preventing and treating opportunistic infections in children. Understanding these illnesses, and testing agents to prevent and treat them, must become higher priorities in the immediate future.