Zika virus infection evaluation of infants: Difference between revisions
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Revision as of 03:34, 22 September 2017
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Zika virus infection Microchapters |
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Zika virus infection evaluation of infants On the Web |
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American Roentgen Ray Society Images of Zika virus infection evaluation of infants |
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Risk calculators and risk factors for Zika virus infection evaluation of infants |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
According to the CDC, Zika virus testing is recommended among 1) infants with microcephaly or intracranial calcifications born to women who traveled to or resided in an area with Zika virus transmission while pregnant, or 2) infants born to mothers with positive or inconclusive test results for Zika virus infection. When an infant is born with microcephaly or intracranial calcifications to a mother who was potentially infected with Zika virus during pregnancy, the infant should be tested for Zika virus infection and ophthalmologic examination. For an infant without microcephaly or intracranial calcifications born to a mother who was potentially infected with Zika virus during pregnancy, subsequent evaluation is dependent on results from maternal Zika virus testing. Developmental monitoring and screening during the first year of life is recommended for all children with congenital Zika virus infection.
Evaluation of Infants
- Pediatric health care providers should work closely with obstetric providers to identify infants whose mothers were potentially infected with Zika virus during pregnancy (see Travel Notice), and review fetal ultrasounds and maternal testing for Zika virus infection (see Evaluation of Pregnant Women).[1]
- Zika virus testing is recommended for the following infant groups:[1]
- Infants with microcephaly or intracranial calcifications born to women who traveled to or resided in an area with Zika virus transmission while pregnant
- Infants born to mothers with positive or inconclusive test results for Zika virus infection.
- For infants with laboratory evidence of a possible congenital Zika virus infection, additional clinical evaluation and follow-up is recommended.
- Health care providers should contact their state or territorial health department to facilitate testing. As an arboviral disease, Zika virus disease is a nationally notifiable condition.[1]
Recommendations for Infants with Microcephaly or Intracranial Calcifications Detected Prenatally or at Birth Whose Mothers Were Potentially Infected with Zika Virus During Pregnancy
A) Recommended Zika virus laboratory testing for infants[1]
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Recommended Zika virus laboratory testing for infants when indicated*
*Indications for testing include 1) infants with microcephaly or intracranial calcifications born to women who traveled to or resided in an area with Zika virus transmission while pregnant, or 2) infants born to mothers with positive or inconclusive test results for Zika virus infection. |
- For the purpose of evaluating an infant for possible congenital Zika virus infection, microcephaly is defined as occipitofrontal circumference less than the third percentile, based on standard growth charts (e.g., Fenton, Olsen, CDC, or WHO growth curves) for sex, age, and gestational age at birth. For a diagnosis of microcephaly to be made, the occipitofrontal circumference should be disproportionately small in comparison with the length of the infant and not explained by other etiologies (e.g., other congenital disorders). If an infant’s occipitofrontal circumference is equal to or greater than the third percentile but is notably disproportionate to the length of the infant, or if the infant has deficits that are related to the central nervous system, additional evaluation for Zika virus infection might be considered.
- When an infant is born with microcephaly or intracranial calcifications to a mother who was potentially infected with Zika virus during pregnancy, the infant should be tested for Zika virus infection. In addition, further clinical evaluation and laboratory testing is recommended for the infant.
- The mother should also be tested for a Zika virus infection, if this testing has not already been performed during pregnancy. An ophthalmologic evaluation, including retinal examination, should occur during the first month of life, given reports of abnormal eye findings in infants with possible congenital Zika virus infection.
- For infants with any positive or inconclusive test findings for Zika virus infection, health care providers should report the case to the state, territorial, or local health department and assess the infant for possible long-term sequelae. This includes a repeat hearing screen at age 6 months, even if the initial hearing screening test was normal, because of the potential for delayed hearing loss as has been described with other infections such as cytomegalovirus.
- For infants with microcephaly or intracranial calcifications who have negative results on all Zika virus tests performed, health care providers should evaluate for other possible etiologies and treat as indicated.
- The following algorithm shows the interim guidelines for the evaluation and testing of infants with microcephaly* or intracranial calcifications whose mothers traveled to or resided in an area with Zika virus transmission during pregnancy§.
| Microcephaly or intracranial calcifications detected prenatally or at birth | |||||||||||||||||||||
| Perform Zika virus testing and other clinical evaluation in infant | |||||||||||||||||||||
| Positive or inconclusive test for Zika virus infection in infant | Negative tests for Zika virus infection in infant | ||||||||||||||||||||
| Report case and assess infant for possible long-term seqelae | Evaluate and treat for other possible etiologies | ||||||||||||||||||||
Microcephaly defined as occipitofrontal circumference less than the third percentile for gestational age and sex not explained by other etiologies
*Laboratory evidence of Zika virus infection includes 1) detectable Zika virus, Zika virus RNA, or Zika virus antigen in any clinical sample, or 2) positive Zika virus immunoglobulin M with confirmatory neutralizing antibody titers that are ≥4-fold.
§higher than dengue virus neutralizing antibody titers in serum or cerebrospinal fluid. Testing would be considered inconclusive if Zika virus neutralizing antibody titers are <4-fold higher than dengue virus neutralizing antibody titers.
Algorithm adapted from the Centers for Disease Control and Prevention [2], Retrieved on February 1st, 2016.[1]
B) Recommended clinical evaluation and laboratory testing for infants with possible congenital Zika virus infection[1]
For all infants with possible congenital Zika virus infection, perform the following:
- Comprehensive physical examination, including careful measurement of the occipitofrontal circumference, length, weight, and assessment of gestational age.
- Evaluation for neurologic abnormalities, dysmorphic features, splenomegaly, hepatomegaly, and rash or other skin lesions. Full body photographs and any rash, skin lesions, or dysmorphic features should be documented. If an abnormality is noted, consultation with an appropriate specialist is recommended.
- Cranial ultrasound, unless prenatal ultrasound results from third trimester demonstrated no abnormalities of the brain.
- Evaluation of hearing by evoked otoacoustic emissions testing or auditory brainstem response testing, either before discharge from the hospital or within 1 month after birth. Infants with abnormal initial hearing screens should be referred to an audiologist for further evaluation.
- Ophthalmologic evaluation, including examination of the retina, either before discharge from the hospital or within 1 month after birth. Infants with abnormal initial eye evaluation should be referred to a pediatric ophthalmologist for further evaluation.
- Other evaluations specific to the infant’s clinical presentation.
For infants with microcephaly or intracranial calcifications, additional evaluation includes the following:
- Consultation with a clinical geneticist or dysmorphologist.
- Consultation with a pediatric neurologist to determine appropriate brain imaging and additional evaluation (e.g., ultrasound, computerized tomography scan, magnetic resonance imaging, and electroencephalogram).
- Testing for other congenital infections such as syphilis, toxoplasmosis, rubella, cytomegalovirus infection, lymphocytic choriomeningitis virus infection, and herpes simplex virus infections. Consider consulting a pediatric infectious disease specialist.
- Complete blood count, platelet count, and liver function and enzyme tests, including alanine aminotransferase, aspartate aminotransferase, and bilirubin.
- Consideration of genetic and other teratogenic causes based on additional congenital anomalies that are identified through clinical examination and imaging studies.
C) Recommended long-term follow-up for infants with possible congenital Zika virus infection[1]
- Report case to state, territorial, or local health department and monitor for additional guidance as it is released.
- Conduct additional hearing screen at age 6 months, plus any appropriate follow-up of hearing abnormalities detected through newborn hearing screening.
- Carefully evaluate occipitofrontal circumference and developmental characteristics and milestones throughout the first year of life, with use of appropriate consultations with medical specialists (e.g., pediatric neurology, developmental and behavioral pediatrics, physical and speech therapy).
Recommendations for Infants without Microcephaly or Intracranial Calcifications Whose Mothers Were Potentially Infected with Zika Virus During Pregnancy
The following are the interim guidelines for the evaluation of infants without microcephaly or intracranial calcifications whose mothers were potentially infected with Zika virus during pregnancy:[1]
- For an infant without microcephaly or intracranial calcifications born to a mother who was potentially infected with Zika virus during pregnancy, subsequent evaluation is dependent on results from maternal Zika virus testing.
- If the test results for the mother were negative for Zika virus infection, the infant should receive routine care (e.g., newborn metabolic and hearing screens).
- If the mother received positive or inconclusive results of tests for Zika virus infection, the infant should be tested for a possible congenital Zika virus infection.
- If the results of all of the infant’s tests are negative for evidence of Zika virus infection, then no further Zika virus testing and evaluation is recommended.
- If any of the infant’s samples test positive or inconclusive, then the infant should undergo further clinical evaluation.
- The infant should also be followed to assess for possible long-term sequelae, and the infant’s case should be reported to the state, territorial, or local health department.
- Infant follow-up should include a cranial ultrasound to assess for subclinical findings, unless prenatal ultrasound results from the third trimester demonstrated no abnormalities of the brain. Ophthalmologic examination and a repeat hearing screen are also recommended, as previously described for infants with microcephaly or intracranial calcifications.
- Developmental monitoring and screening during the first year of life is recommended for all children with congenital Zika virus infection.
- If the mother has not undergone any previous testing for Zika virus infection during pregnancy, CDC recommends that she receive testing only if she reported symptoms consistent with Zika virus disease during or within 2 weeks of any time spent in an area with ongoing Zika virus transmission while she was pregnant.
- If the mother has any positive or inconclusive findings from tests for Zika virus infection, then the infant should undergo testing for evidence of a congenital Zika virus infection.
- If the mother has not received any previous testing for Zika virus, and did not report clinical illness consistent with Zika virus disease during pregnancy, no further testing of the mother or infant is recommended.
- The following algorithm shows the interim guidelines for the evaluation and testing of infants without microcephaly* or intracranial calcifications whose mothers traveled to or resided in an area with Zika virus transmission during pregnancy:[1]
| No microcephaly or intracranial calcifications detected prenatally or at birth | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive or inconclusive test for Zika virus infection in mother prior to delivery | No Zika virus testing performed on mother prior to delivery | Negative tests for Zika virus infection in mother prior to delivery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Test mother if she reported cliniical illness consistent with Zika virus disease during pregnancy | No testing indicated if mother did not report clinical illness consistent with Zika virus disease during pregnancy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive or inconclusive test for Zika virus infection in mother | Negative tests for Zika virus infection in mother | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Conduct thorough physical examination and perform Zika virus testing in infant | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive or inconclusive test for Zika virus infection in infant | Negative tests for Zika virus infection in infant | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Perform additional clinical evaluation, report case, and assess for possible long-term sequelae | Routine care of infant, including appropriate follow-up on any clinical findings | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Microcephaly defined as occipitofrontal circumference less than the third percentile for gestational age and sex not explained by other etiologies
*Laboratory evidence of Zika virus infection includes 1) detectable Zika virus, Zika virus RNA, or Zika virus antigen in any clinical sample, or 2) positive Zika virus immunoglobulin M with confirmatory neutralizing antibody titers that are ≥4-fold.
§higher than dengue virus neutralizing antibody titers in serum or cerebrospinal fluid. Testing would be considered inconclusive if Zika virus neutralizing antibody titers are <4-fold higher than dengue virus neutralizing antibody titers. If mother reported clinical illness consistent with Zika virus disease during pregnancy and testing is indicated, perform Zika virus reverse transcription-polymerase chain reaction testing on serum specimen collected ≤7 days after illness onset when possible. Perform Zika and dengue virus IgM and neutralizing antibodies on serum specimens collected ≥4 days after illness onset. Clinical illness is consistent with Zika virus disease if two or more symptoms (including acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) are present during or within 2 weeks of any time spent in an area with ongoing Zika virus transmission.
Algorithm adapted from the Centers for Disease Control and Prevention [3], Retrieved on February 1st, 2016.[1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Staples JE, Dziuban EJ, Fischer M, Cragan JD, Rasmussen SA, Cannon MJ; et al. (2016). "Interim Guidelines for the Evaluation and Testing of Infants with Possible Congenital Zika Virus Infection - United States, 2016". MMWR Morb Mortal Wkly Rep. 65 (3): 63–7. doi:10.15585/mmwr.mm6503e3. PMID 26820387.