US guidelines on paediatric care updated (March 2005)
The American Guidelines for the Use of Antiretroviral Agents in Paediatric HIV Infection were updated on 24 March 2005. The appendix, ‘Characteristics of available antiretroviral drugs’ has been extensively modified to include up-to-date drug information, including updated information about paediatric dosing and new drug formulations.
The updated appendix also includes a matrix based on Table 18 in the Adult Guidelines (adverse drug reactions) and three matrices based on Tables 19-21 in the Adult Guidelines (drug interactions between antiretrovirals and other drugs).
The paediatric guidelines were developed by the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children, which reviews new data on an ongoing basis and provides regular updates to the guidelines.
The updated guidelines document is available in the Paediatric Guidelines section of the Guidelines page on the AIDSinfo site:
There are so few changes to these guidelines that anyone who has already printed either the January 2004 or November 2004 guidelines would do better to save their paper, and just note the few new additions.
If this is the first time you have looked at the document, then it does contain a wealth of background information and references. that form a useful resource This latest version however is virtually unchanged: the only differences appear to be in the Appendix listing ‘Characteristics of Available Antiretroviral Drugs’ that now include links to Black Box Warning matrices for various drugs, particularly abacavir; and half a dozen references have been removed.
Interestingly no publications from 2004 appear to have been reviewed for the 2005 guidelines, not even Katherine Luzuriaga’s NEJM paper recommending 4-drug, PI-containing therapy for infants.
The indications for starting treatment in children less than or more than 12 months of age are unchanged. This is despite inclusion in Table 3 and Figures 1-4 of the HIV Paediatric Prognostic Markers Collaborative Study Group (HPPMCSG) data that clearly show that the CD4% cut-offs should be higher in younger infants and lower in older children. 
Please refer to the current PENTA guidelines for a discussion as to how these data can be used in practice. 
Striking differences persist in prescribing habits between the US and Europe, particularly with regard to the use of abacavir as part of first line therapy for children. These guidelines will not change these discrepancies. There is no discussion of the pros and cons of treatment interruptions in children.
Hopefully the next version of the guidelines will include a reflection on the data from the HPPMCSG and will acknowledge that judiciously delaying initiation of treatment may be in the best interest of selected children.
- HIV Paediatric Prognostic Markers Collaborative Study Group. Short-term risk of disease progression in HIV-1-infected children receiving no antiretroviral therapy or zidovudine monotherapy: a meta-analysis. Lancet Nov 2003; 362: 1605-11.
- Castelli-Gattinara G et al. 2004 PENTA guidelines for the use of antiretroviral therapy in paediatric HIV infection. HIV Medicine, July 2004 (Volume 5, Supplement 2). Available to download free at: