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Background: The newborn infant is a complexly organized, competent being, who plays an active role in shaping their environment through their increasing skills in autonomic regulation, motor control, regulation of state and social interaction. Infants born to HIV positive mothers, are exposed to HIV and antiretroviral therapy inutero, and may experience adverse effects from this. Methods: A cross-sectional study of 132 mother-infant dyads from a large public health hospital in South Africa. Infants were assessed using the Neonatal Behavioural Assessment Scale on day two of life, and mothers mental health assessed using the Edinburugh Postnatal Depression Scale. Medical and demographic data on mothers and infants was collected, including maternal age, HIV status, length of time on antiretrovirals, relationship status, employment status, gravid status, mode of delivery, infant anthropometrics and infant gender. Data was input into IBM SPSS statistics 21, where frequencies and percentages for descriptive analysis, and Chi-square and student’s two sample t-tests were run to compare data from HIV infected-exposed and HIV uninfected-unexposed mothers and infants. Results: HIV exposed infants were smaller than HIV unexposed infants, even though low birth weight was an exclusion criteria. Statistically significant differences were found between HIV exposed and unexposed infants in neurobehavioiral items of social interaction (p = 0.00), motor system (p = 0.00) and state organization (p = 0.01), with HIV exposed infants performing less optimally in these domains. HIV exposed infants also presented with more abnormal reflexes. Infants born to depressed mothers showed superior motor skills, state organization and state regulation than infants born to mothers who did not score in the possibly depressed range. Conclusions: HIV exposed infants have inferior neurobehavioural functioning, which may affect their quality of life and ability to develop a reciprocal relationship with a primary caregiver. This may have an effect on development, behaviour and mental health in later childhood. HIV exposed infants shoud be monitored closely and their functioning in autonomic stability, motor control, resualtion of state and social interaction assessed regularly. Guidance for caregivers in incorporating strategies into the care of these infants is essential to buffer the possible long term negative effects on development.
This study aimed to explore the neurobehavioral functioning of HIV exposed infants born to mothers seropositive to HIV-1. The objectives were to observe the neurobehavioral functioning of HIV exposed infants assessed on the NBAS [1] and compare these to the neurobehavioral functioning of unexposed infants. It further aimed to correlate infant neurobehavior to self-reported maternal mental health measured on the Edinburgh Postnatal Depression Scale (EPDS) [29]. An exploratory cross-sectional cohort study was completed at a large academic hospital in KwaZulu-Natal (KZN), South Africa, over a six-month period [30]. A preliminary visit was done to the obstetric ward prior to the commencement of the study in order to determine the population size. The ward intake book, which details maternal age, mode of delivery and adverse events (such as foetal distress, meconium-stained liquor, stillbirth, NICU admission or maternal high care transfer), infant gender, and a singleton or multiple birth, was perused for the number of admissions which would meet the maternal and infant inclusion criteria. These criteria were: the mothers had to be of adult maternal age (21 years – 39 years) residing in the EThekwini municipality of KZN and booked for delivery at the academic hospital. They needed to have attended at least two antenatal appointments, a singleton pregnancy, a completed HIV test and results available, and received ART in option B + if HIV positive. The infant had to be a well-baby (indicating that they only need standard practice neonatal nursing or medical care), attain APGAR scores at or above 7/10, be in the care of their mother in the obstetric ward, delivered at or after 38 weeks gestation. A total of 130 admissions meeting these criteria were noted in a month. There were no available published studies in this population to assist in calculating the sample size with a power analysis, and the researcher aimed for a sample size of 50 in each of the two mother-infant dyad groups (HIV positive mothers with exposed infants and HIV negative mothers with unexposed infants) in line with previous studies [18] and statistical guidance. Considering the fact that the only previous study on a similar population was published in 1997, prior to the widespread use of ART during pregnancy to prevent vertical transmission of HIV-1 [18], an exploratory study in the present-day South African context was warranted. The study sample comprised 132 mother-infant dyads. After screening the ward intake log, mothers meeting the inclusion criteria were invited and recruited into the study with their infant, following additional screening through a discussion about illnesses or complications experienced during their pregnancy (such as diabetes mellitus, alcohol use, smoking, drug use, significant infections or pre-eclampsia) or with their infant directly after birth, and gaining informed consent. The hospital used in the research is a baby-friendly hospital, which strongly encourages breastfeeding and attachment. Infants are placed on their mother’s chest after delivery and sleep in the hospital bed with their mother, with the only period of separation being when the mother goes to do her ablutions, shower, or collect food from the trolley in the ward. Infants needing specialized care are transferred to the high care or intensive care units, and these infants were excluded from the study. The researcher completed the NBAS prior to reviewing the maternal or infant medical records in order to maintain blindness to HIV status prior to testing the infant. A total of 80 HIV-positive mothers and their exposed infants and 52 HIV-negative mothers and their unexposed infants participated in the study at the initial point of contact in the obstetric ward. Infants were assessed using the NBAS [1] in the presence of their mother on day two of life before being discharged to a step-down facility or home. The NBAS is a comprehensive neurobehavioral assessment used worldwide in research and clinical settings and is sensitive to subtle environmental effects and pre-, peri, and postnatal variables [1]. It is based on the assumption that the neonate is competent and complexly organized. The infant’s behavior was assessed on 28 behavioral items and 20 reflex items. The behavioral items (habituation, orientation, motor, range of state, regulation of state, autonomic stability) are scored on a nine-point likert scale. In contrast, the reflex items are scored on a four-point scale. The researcher is an experienced clinician in Occupational Therapy, with appropriate training in the administration and interpretation of the NBAS assessment. As an additional measure of reliability, the researcher watched the NBAS administration training video at the beginning of each week of data collection to ensure administration remained accurate. A sample of 20 assessment forms with in-depth descriptions of the infant’s behaviour in each of the 28 behavioral and 20 elicited items were independently scored and later compared to the scores given by the researcher. These compared scores were manually computed, and reached a 99% match on the behavioural items, and a 100% match on the elicited items, meeting inter-rater reliability criteria of the NBAS [1]. The infant’s medical file was perused after the NBAS assessment had been completed to address potential examiner bias. The medical files provided birth type, APGAR scores, weight, length, head circumference, HIV exposure, HIV-prophylactic medication if HIV exposed [31] and immunizations received. The method of feeding was verified with the infant’s mother. Maternal medical data were accessed from the medical file after examination of the infant. Information gathered included HIV status, the length of time the mother had been taking ART if she is HIV positive [31], and age. Demographic information such as relationship status and employment status was gained from the mother. In addition, the mother independently completed the EPDS to assess her mental health whilst the researcher was in the ward and available to answer questions for clarity. The EPDS is a 10 item self-report questionnaire assessing the symptoms of depression. It focuses on cognitive and affective symptoms, omitting somatic symptoms often associated with depression (headaches, nausea, change in weight, and appetite), which may be confounded by pregnancy, and is thus a reliable screening tool for “perinatal” depression. Each reported item is scored on a four-point likert scale, with a total range of 0–30. It assesses how the responder has been feeling in the last seven days. A cut-off score of ≥ 10 is considered indicative of possible depression [29]. The scale has been validated in a previous South African study [20]. Ethical approval was granted by the KZN Health Research and Knowledge Management Directorate of the provincial Department of Health (ref no. HRKM320/15 K2_2015RP40_914) and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (approval number BFC354/15). Permission was sought and granted by the Hospital CEO, the Matron in charge of Obstetric Nursing, and the sister in charge of the ward to access the unit. All mothers read the participant information sheet, read and signed informed consent independently prior to testing. There was no change to routine nursing or medical care as a result of participation or non-participation in the study. Data from the NBAS, EPDS, and medical files were input to Microsoft excel 2016 and imported into IBM SPSS Statistics 21. Frequencies and percentages were used to describe categorical data while continuous data were summarized in means and standard deviations (SD), with a 95% confidence interval. Demographic variables were analyzed using Chi-square (χ2) tests and student’s two-sample t-tests, with equal variations assumed or not assumed depending on Levine’s test for equality of variances. NBAS behavioral and reflex items were analyzed in the seven-cluster scoring system developed by Lester and colleagues. This scoring system is widely used in research and allows for effective data reduction by reducing the behavioral items into seven clusters. These include habituation (4 items), orientation (7 items), motor (5 items), range of state (4 items), regulation of state (4 items), autonomic stability (3 items), and reflexes (20 items) [1]. T-tests were computed to compare the data collected from the HIV exposed and unexposed infants and their mothers. Missing data occurred in the NBAS assessments of some infants: in the habituation package if they were not asleep at the time of the assessment, or woke up during the administration of the items, and if the assessment had to be stopped because the infant became too dysregulated or was too fragile to complete [1]. In the cases of these infants, scores were calculated for the items they were able to participate in.
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