New CDC Guidance on Caring for Infants With Congenital Zika

Janis C. Kelly

October 20, 2017

UPDATED October 23, 2017 // The Centers for Disease Control and Prevention (CDC) has released updated clinical guidance on caring for infants who have or might have congenitally acquired Zika infection.

Margaret Honein, PhD, MPH, CDC, Chief, Birth Defects Branch, CDC National Center on Birth Defects and Developmental Disabilities, told Medscape Medical News,"The updated interim guidance is in response to three main concerns," Margaret Honein, PhD, MPH, chief of the Birth Defects Branch at the CDC National Center on Birth Defects and Developmental Disabilities, told Medscape Medical News. "In July 2017, CDC updated the Zika guidance for pregnant women, which was intended to reduce the possibility of false-positive results in the setting of lower pretest probability (related to the lower prevalence of reported Zika virus infections). However, there is the possibility that the lack of routine testing might delay identification of some infants, particularly those without clinical findings apparent at birth, but who might have complications from congenital Zika virus infection. Furthermore, optimal tests, types of specimens to test, and timing to test for congenital Zika virus infection are unknown. This update incorporates additional findings associated with congenital Zika virus infection that healthcare providers should be aware of."

The new guidance, which incorporates data gathered during the past year, stratifies infants into three risk categories on the basis of maternal laboratory test results, presence or absence of birth defects, and laboratory testing for Zika infection in the infant. The recommendations cover diagnosis, evaluation, monitoring, and management approaches for each risk group.

The update also cancels some recommendations from the prior version, issued in August 2016. Thyroid screening and hearing screening at 4 to 6 months of age are no longer recommended because of a lack of data on whether these screenings are needed. Dr Honein said that CDC has received no reports of late-onset hearing loss.

"There's a lot we still don't know about Zika, so it's very important for us to keep a close eye on these babies as they develop," said CDC Director Brenda Fitzgerald, MD, in a press statement. "Learning how best to support them will require a team approach between healthcare providers and families."

Congenital Zika syndrome is associated with a pattern of birth defects that includes brain abnormalities, vision problems, hearing loss, and problems moving limbs. Infants with congenital infection may appear healthy at birth but may already have underlying brain defects or other Zika-related health problems.

Therefore, the updated recommendations emphasize the importance of pediatric healthcare providers assessing risk for congenital Zika virus infection, communicating closely with obstetrical providers, and maintaining a high index of suspicion for late-developing problems in infants born to mothers with possible Zika virus exposure during pregnancy, even if none are apparent at birth.

The guidance was developed by Tolulope Adebanjo, MD, from the CDC's Epidemic Intelligence Service, Atlanta, Georgia, and colleagues in collaboration with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and other clinical experts in August 2017.

In all cases, the standard evaluation recommended at birth and during each well visit for infants with possible Zika virus exposure in utero includes a comprehensive physical exam (including growth parameters), developmental monitoring and screening using validated tools recommended by the American Academy of Pediatrics, and vision screening as recommended by the American Academy of Pediatrics. The guideline also recommends newborn hearing screen at birth, preferably with automated auditory brainstem response.

For infants with birth defects consistent with congenital Zika syndrome born to mothers with possible Zika virus exposure during pregnancy (regardless of the mother's Zika virus test results), the experts have expanded the list of potential problems to monitor to include difficulty breathing, difficulty swallowing, and hydrocephaly.

The authors note that care and follow-up of these infants no longer depends on the infants' Zika virus testing results.

"Because infants with clinical findings consistent with congenital Zika syndrome are at risk for developmental delay and disabilities, referrals to a developmental specialist and early intervention service programs are recommended, and family support services should be provided," the authors write.

They also recommend consideration of consultations for infectious disease evaluation, clinical genetics, and neurology by age 1 month for comprehensive neurologic examination. Diagnostic auditory testing at age 4 to 6 months is no longer recommended for infants who passed the initial testing.

For infants without birth defects born to mothers with laboratory evidence of possible infection during pregnancy, the guidance recommends Zika virus testing. They should also receive a head ultrasound and comprehensive ophthalmologic exam performed by age 1 month to rule out subclinical brain and eye changes. Monitoring at each well-child visit should include impaired visual acuity/function, hearing problems, developmental delay, or delay in head growth.

If the laboratory test shows evidence of congenital Zika virus infection, the infant should be managed following recommendations for infants with clinical findings. A change from the 2016 guidance is that diagnostic auditory testing at age 4 to 6 months or behavioral audiology at age 9 months is no longer recommended if the baby has passed initial hearing screen by automated auditory brainstem response.

In contrast, if the laboratory test shows no evidence of congenital Zika virus infection, the infant should receive routine pediatric care.

Finally, infants without birth defects born to mothers with possible Zika virus exposure during pregnancy, but without laboratory evidence of Zika virus infection during pregnancy, should receive standard evaluation at each well-child visit as well as routine preventive care and immunizations.

This group includes infants born to mothers not tested during pregnancy or those whose Zika test could have been negative because of timing, sensitivity, or specificity issues. The authors write, "Because the latter issues are not easily discerned, all mothers with possible exposure to Zika virus during pregnancy who do not have laboratory evidence of possible Zika virus infection, including those who tested negative with currently available technology, should be considered in this group."

The update also includes additional recommendations for prenatal diagnosis of congenital Zika virus infection, including use of ultrasound and amniocentesis.

Dr. Honein said, "We have learned a lot about Zika, but some important questions remain. What are the full range of complications that Zika can cause following infection during pregnancy? Will babies without clinical findings apparent at birth have serious problems later, such as vision loss or seizures? What services might improve outcomes among infants affected by congenital infection? We know that babies will continue to be born with congenital Zika syndrome in 2017 and beyond, underscoring the need to stay committed to following these infants to understand these critical questions and ensuring care and services for these families."

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2017;66:1089-1099. Full text

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