CDC, AAP Update Recs for Infants and Congenital Zika Virus

Troy Brown, RN

July 22, 2016

The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) have updated recommendations for the clinical evaluation and management of infants with congenital Zika virus infection or suspected infection.

The risk for microcephaly in infants exposed to the virus prenatally is one of Zika’s biggest threats, and recent data suggest that babies exposed in late pregnancy may not have the same risk as those exposed earlier in pregnancy. However, a great deal of uncertainty still exists, and infants born without apparent microcephaly or who appear asymptomatic may develop microcephaly and other medical issues as they grow.

For this reason, experts met on July 21 to discuss revisions to the last CDC recommendations, which were released in late February 2016.

The group made recommendations in three areas of concern: evaluation of infants with suspected or confirmed congenital Zika virus infection, outpatient care and follow-up for symptomatic infants with congenital Zika virus infection, and outpatient care and follow-up for infants without apparent abnormalities at birth.

Common themes in each of the three groups include diagnostic testing, the need for multidisciplinary care, the need for anticipatory guidance beginning during pregnancy about the type of care the baby will require and the need for early identification of problems, and the need for parental support caring for a baby who will likely have sleep and crying difficulties as well as other complex needs.

All Infants With Suspected Congenital Zika Virus Infection

Discussions are ongoing with regard to Zika infant diagnostic testing, which will likely include Immunoglobulin M (IgM) and polymerase chain reaction (PCR) testing on infant specimens. Although final recommendations are pending, infection is considered to be possible or confirmed if infant PCR or IgM testing results are positive.

These infants require a comprehensive physical examination that includes careful head circumference measurement and assessment of length, weight, and gestational age; and evaluation for neurologic abnormalities, dysmorphic features, liver or spleen enlargement, and the presence of rash or other skin lesions, the group concluded.

Infants with suspected or confirmed congenital Zika infection also need a hearing screen per universal screening and a cranial ultrasound before discharge from the hospital.

A pediatric ophthalmologist or an ophthalmologist with expertise in the care and management of children should examine the child within 1 month after birth, unless infant testing for Zika infection has returned negative.

A complete blood count to evaluate for thrombocytopenia should be obtained, and other testing as appropriate on the basis of the infant's clinical exam should be ordered, the recommendations suggest.

Symptomatic Infants With Congenital Zika Virus Infection

These infants will require extensive evaluation and complex care. Clinicians should consider transferring them to a facility with pediatric subspecialty care and services that include, at a minimum, neonatal/pediatric intensive care, endocrinology, orthopedics, neurology, ophthalmology, genetics, infectious disease, pulmonology, care for feeding issues, and family/social support, including palliative care.

Healthcare providers should observe standard precautions when handling body fluids. Laboratory studies should include a complete blood count and a complete metabolic panel that includes liver function tests.

These infants require gestational age assessment. They also need careful assessment of head circumference, length, and weight at birth, monthly until age 6 months, and further according to clinical judgment.

It can be difficult to measure head circumference in infants with severe microcephaly or an abnormal head shape; for this reason, measurement should be from the glabella to the point of the occipital bone. Infants with congenital Zika infection can also have a normal head size, and healthcare providers need to be educated in this regard.

Ophthalmology and audiologic evaluations (otoacoustic emissions testing or auditory brainstem response testing) should be conducted before hospital discharge, according to the group’s recommendations. Hearing screening should be repeated at age 4 to 6 months if it was normal at birth. Infants with a normal ophthalmology screening at birth should receive a full examination, including retinal examination, at age 3 months.

A head ultrasound should be performed and advanced imaging (computed tomography or magnetic resonance imaging) should be considered before discharge. Other evaluations should be conducted and other management specific to the baby's clinical exam should be set up as needed.

Symptomatic infants require monthly healthcare visits and increased surveillance. These infants should receive regularly scheduled immunizations; pertussis-containing immunizations are not contraindicated in children with central nervous system malformations, but uncontrolled seizures may be a precaution for vaccines containing pertussis.

Children should receive developmental screening at each visit, as abnormalities may become apparent as the infant grows. Children with a screening abnormality in any domain should be referred for a formal developmental evaluation. A complete neurological exam (eg, for Dubowitz syndrome) should be performed at ages 1 and 2 months and as necessary thereafter. Children with any abnormalities should be referred for further observation. Children should be observed closely for new onset of seizure activity with subtle symptoms.

The recommendations include consideration of screening of any child with congenital Zika infection for central hypopituitarism/hypothalamic dysfunction. The earliest manifestation of this would be congenital hypothyroidism, which newborn thyroid stimulating hormone screening may miss. The recommendations suggest evaluating Total and Free T4 at age 2 weeks. If abnormal, a workup for hypocortisolism should be conducted; if normal, screening at age 3 months should be repeated. Prolactin levels can also be assessed at age 3 months. Observation should be made for possible growth hormone deficiency by following linear growth.

Care of infants with anomalies should be family-centered and family-guided, with caregivers participating in decision-making. Anticipatory guidance on development, function, feeding, and long-term prognosis should be provided to caregivers prenatally, and assistance should be available for the family with using community resources and with developing coping mechanisms for soothing babies who may be extremely irritable and cry excessively.

Breastfeeding can enhance maternal-infant bonding and reduce stress. Mothers who wish to breastfeed or give their infant pumped breast milk should be referred to a lactation consultant. Observation of breastfeeding infants should be made for feeding difficulties and monitored with a pulse oximeter during feeding.

Caregivers of these infants may need respite care and should be monitored for other stresses including stress related to financial issues and depression, the group recommended.

Coordination of care is vital for these infants. It should be ensured that testing and consultations are performed, results for tests including those performed during the newborn period are obtained, abnormal results are acted on appropriately, regardless of who provides the care, and that subspecialty and service recommendations made during the newborn evaluation are completed or scheduled. The infant's growth, development, and neurologic status should be monitored after referrals have been made and throughout subspecialty care.

Telemedicine can be an important resource for caregivers as well, as it can provide a means for visual assessment of seizures, particularly infantile spasms, and audio assessment of excessive crying.

Referrals should include: audiology, neurology, ophthalmology, endocrinology, pulmonology, physical therapy, occupational therapy, speech therapy, rehab medicine, orthopedics/orthoptics, cerebral palsy clinic, comprehensive care clinic, lactation specialist, neurosurgery, plastic surgery, palliative care, community/psychosocial care resources.

Asymptomatic Infant, but Considered "At Risk"

These are infants whose mother may not have been tested for Zika infection but who are considered at risk for the infection. These mothers should receive diagnostic Zika testing, which may include Zika PCR testing on the placenta, which may yield faster results.

There is relatively little information on this group of infants and assessment can be difficult because many common problems in healthy infants can also be present in infants with Zika infection. In addition, it can be stressful for parents to cope with the uncertainty of not knowing whether their child will develop symptoms later. For these reasons, clinicians need to provide caregivers with the most current information available and help them identify supports in the community, according to the recommendations.

Clinicians need to educate caregivers on what to look for in their child and when to contact the healthcare provider.

These infants require a comprehensive physical examination, including careful head circumference measurement and assessment of length, weight, and gestational age. The infant should also be evaluated for neurologic abnormalities, dysmorphic features, liver or spleen enlargement, and rash or other skin lesions. They should receive a hearing screen per universal newborn screening before hospital discharge. These infants should also receive a head ultrasound if maternal testing is positive or if there are concerns for follow-up, before discharge from the hospital.

In addition to these interventions, asymptomatic infants should receive normal newborn care and close observation, the group advised.

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