COMMENTARY

Suspect Congenital Zika? What to Do Next

Cynthia A. Moore, MD, PhD

Disclosures

July 30, 2018

Editorial Collaboration

Medscape &

Hello. I'm Dr Cynthia Moore, a pediatrician, clinical geneticist, and a chief medical officer in the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention (CDC). Today I will discuss the critical importance of follow-up for infants and children with possible congenital Zika virus infection and CDC's recommendations for evaluating these infants.

Zika virus infection during pregnancy can cause microcephaly and severe abnormalities of the brain and spinal cord in offspring. In addition, Zika virus can cause eye abnormalities with vision impairment, hearing loss, seizures, congenital joint contractures, and delayed development. With age, infants with the most severe phenotype, known as congenital Zika syndrome,[1] develop multiple disabilities, including cerebral palsy. However, the severity of clinical outcomes is likely a spectrum, and we have little information about problems at the milder end of this spectrum or the long-term developmental consequences of the infection. Data from the United States showed that about 1 in 10 babies born to mothers with laboratory evidence of Zika virus infection during pregnancy had birth defects that have been associated with Zika.[2]

These concerning outcomes, along with the remaining questions about the long-term effects of Zika virus infection, underscore the continued need for your help in providing clinical care for these infants and children. To ensure optimal care, it's imperative to follow the latest clinical guidance[3]and share pertinent medical information with your state or local health department.

CDC's clinical guidance begins with testing during pregnancy. If an obstetric provider suspects possible maternal Zika virus exposure, and the patient has symptoms or ongoing exposure,[4] laboratory testing is performed. After birth, pediatricians should ask about possible maternal Zika virus exposure. All infants should receive a standard evaluation at birth and during subsequent well-child checks. This includes a comprehensive physical exam with assessment of growth parameters; age-appropriate vision and developmental monitoring and screening; and a standard newborn hearing screening, preferably using automated auditory brainstem response (ABR).

If no maternal Zika virus exposure is identified and the infant does not present with findings consistent with congenital Zika syndrome, Zika virus testing is not routinely recommended and customary pediatric care should be provided.

However, if a mother has laboratory evidence of Zika virus infection or an infant presents with findings consistent with congenital Zika syndrome, there are important recommendations to follow. The remaining guidance divides these infants into three categories for care.

Infants with birth defects. The first category comprises infants with birth defects (such as microcephaly) that are consistent with congenital Zika syndrome, regardless of maternal test results. These infants should receive additional evaluations, including Zika virus testing, a head ultrasound, a comprehensive eye exam, and an automated ABR by 1 month of age. These infants should be referred to a developmental specialist, early intervention services, and additional medical specialists as clinically indicated. Zika virus testing on cerebrospinal fluid (CSF) can be considered for these infants if obtained for other reasons because, in some instances, CSF has been the only sample that tested positive in infants with congenital Zika virus infection. Other causes for birth defects should be explored in the face of a negative workup for Zika virus.

Infants whose mothers might have Zika. The second category comprises infants without birth defects consistent with congenital Zika syndrome who were born to mothers with laboratory evidence of possible or confirmed maternal Zika virus infection. As in the first category, they should receive a standard evaluation, Zika virus testing, a head ultrasound, a comprehensive eye exam, and automated ABR by 1 month of age. If the evaluation is abnormal or the infant has laboratory evidence of congenital Zika virus infection, recommendations for infants with findings consistent with congenital Zika syndrome should be followed.

Infants whose mothers had Zika exposure but no evidence of infection. The third category includes infants without birth defects consistent with congenital Zika syndrome who were born to mothers with possible Zika virus exposure, but without laboratory evidence of infection. Zika virus testing and clinical evaluation beyond the standard of care are not routinely recommended for infants in this category; however, if findings suggestive of congenital Zika syndrome are identified at any time, referral to appropriate specialists is recommended.

Following CDC's guidance can help ensure that your patients receive care based on the best available information. In addition, reporting test results and clinical findings to your state or local health department can help us learn more about these infections and better understand the full impact of congenital Zika virus infection on infants and children. Expanding knowledge about the effects of Zika virus infection in pregnancy helps inform clinical diagnosis, evaluation, and management, and facilitates the development of treatment strategies and referral for additional services.

Thank you for watching. We've developed clinical care roadmaps that you and your patients can use to track screening and testing dates and results. These resources, and many more, can be found on CDC's Zika and Pregnancy website. For other specific questions, reach out to your state or local health department or the CDC by calling 1-800-CDC-INFO (1-800-232-4636).

We appreciate your support in the fight against Zika virus as we learn how to better address this serious threat to mothers, babies, and families.

 Web Resources

Interim Guidance for the Diagnosis, Evaluation, and Management of Infants with Possible Congenital Zika Virus Infection — United States, October 2017.

Pocket Guide: Evaluation for Infants with Possible Congenital Zika Virus Infection

Zika Test Result Interpretation

Roadmap for Babies with Congenital Zika Infection

Roadmap for Babies of Mothers Infected with Zika During Pregnancy Who Appear Healthy

US Zika Pregnancy and Infant Registry Fact Sheet

The Registry: How Does It Work?

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