Zika - Key Information for Pediatricians

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Key Information for Pediatricians

  


Refer to the Centers for Disease Control and Prevention (CDC) Update: Interim Guidance for the Diagnosis, Evaluation, and Management of Infants with Possible Congenital Zika Virus Infection — United States, October 2017 and Clinical Guidance for Healthcare Providers Caring for Infants & Children for up-to-date guidance. Also see the Zika page.

Testing

  • ​There are three types of tests that can be performed on an infant: Molecular, Serologic, and Plaque Reduction Neutralization Testing. Learn more about procedures for testing for Zika virus. See Interim Guidance for Interpretation of Zika Virus Antibody Test Results for additional information.

  • All infants born to mothers with laboratory evidence of Zika virus infection should be tested.

  • All infants with findings suggestive of congenital Zika syndrome and a maternal epidemiologic link suggesting possible transmission (regardless of maternal testing results) should be tested. A Zika virus RNA NAT test should be performed on both infant serum and urine, and Zika virus immunoglobulin M (IgM) antibody should be performed on infant serum. Testing should be performed on specimens collected from infants within 2 days after birth; however, testing specimens collected within the first few weeks to months after birth may still be useful in the evaluation for possible congenital Zika virus infection, especially among infants born in areas without risk of Zika. If testing cerebral spinal fluid (CSF) for another reason, you can consider Zika virus NAT and IgM testing as well.

  • Testing options vary by state, and the time it takes to get results can vary. Pre-approval is required by the CDC prior to submission of any tissue specimens. For pre-approval please contact pathology@cdc.gov and eocevent189@cdc.gov. When CDC performs testing, results will typically be sent to the state or local health department within 3 weeks after specimen receipt. Reporting times for test results may be longer during summer months or when arbovirus activity increases.

  • The CDC now recommends that men with possible Zika virus exposure who are planning to conceive with their partner wait at least 3 months after symptoms or possible exposure (travel to or residence in an area with risk of Zika). These updated recommendations are published in MMWR
  • For additional testing guidance recommendations, including for pregnant women, see the CDC Testing Guidance Web page.

​Infancy Newborn Visit

When a pediatrician sees a newborn around 3 to 5 days after birth, it is critical to ask whether the mother/baby were screened for Zika virus, e.g

  • Where were you living and where did you travel during your pregnancy? What was the length of exposure? Did you regularly use protective measures? See a map of high risk areas.

  • Were you ever concerned about Zika virus infection? Did you get a Zika virus test during pregnancy? What was the result?

  • ​Was there any concern of Zika virus infection when the infant was born? If so, was there testing or imaging performed? If so, what was the result?

 

Evaluation

  • Infants with suspected Zika virus syndrome should undergo a comprehensive physical examination, including a neurologic examination, head circumference, postnatal head ultrasound, standard newborn hearing screening, ophthalmologic examination, and hearing assessment using auditory brainstem response (ABR) testing. Ideally, these procedures should be done by 1 month of age.

  • Additional recommendations include referring to developmental specialists and early intervention services, providing family support services, and considering consultations with subspecialists, such as infectious disease, clinical geneticist, neurologist, and other specialists based on clinical findings.

  • It is recognized that there might be delays in getting appointments with subspecialists or finding subspecialists in rural areas. Zika Care Connect is a new program designed to connect women, parents, and caregivers of infants, and families affected by Zika to recommended health care services. For more information, visit the Zika Care Connect Web site or call the HelpLink at 1-844-677-0447 (toll-free).

Treatment and Follow-up

Follow-up depends on test results and whether abnormalities consistent with congenital Zika syndrome are present. For more detailed information, visit the CDC Follow-Up Care Web page.

Infants with Abnormalities Consistent with Congenital Zika Virus Syndrome Need:

  • A coordinated evaluation by multiple specialists by 1 month of age (eg, audiologist, clinical geneticist endocrinologist, neurologist, family and supportive services, infectious disease specialist, lactation specialist, ophthalmologist, orthopaedist, physiatrist or physical therapist, and pulmonologist [for concerns about aspiration]).

  • ​Like other congenital conditions, children with Congenital Zika Virus Syndrome will need care by a team of subspecialists. This can be very overwhelming for parents, so the American Academy of Pediatrics (AAP) has produced a report and webinar on managing medical complexity in your practice.

Asymptomatic Infants:

Known Characteristics of Infants with Congenital Zika Virus Infection

  • Zika virus appears to primarily target neural progenitor cells resulting in abnormalities from two general mechanisms: (1) destruction of previously developed brain cells; and/or (2) disruption of normal brain development proliferation, migration and differentiation, which slows brain growth and affects neural cell viability.

  • ​Microcephaly and other serious congenital brain malformations. (Some infants have a phenotype consistent with fetal brain disruption sequence, characterized by severe microcephaly, collapse of the skull, overlapping cranial sutures, prominent occipital bone, redundant scalp skin, and severe neurologic impairment. Other infants have congenital brain malformations without microcephaly at birth.)

  • ​​Reported neuroimaging findings include intracranial calcifications; ventriculomegaly and extra-axial fluid; abnormal gyral patterns (e.g., polymicrogyria, schizencephaly); decreased brain parenchymal volume; cortical thinning and malformation; hypoplasia of the cerebellum, cerebellar vermis or brainstem; delayed myelination; and thinning or hypoplasia of the corpus callosum. See the Healthcare Providers Caring for Infants & Children​ for more details.

  • ​Neurologic abnormalities apparent on examination of these infants have included hypertonia, hypotonia, spasticity, hyperreflexia, severe irritability, and seizures. Clinical abnormalities in less severely affected infants with brain malformations may not occur until later when they present with developmental delays and/or seizures.

  • ​Ocular findings reported in infants with presumed or confirmed congenital Zika virus infection have included chorioretinal atrophy or scarring, pigmentary changes, optic nerve hypoplasia, optic disc pallor, increased optic disc cupping, hemorrhagic retinopathy, abnormal retinal vasculature, and glaucoma.

  • ​Other findings seen in infants with congenital Zika virus infection have included clubfoot and contractures of single or multiple joints (arthrogryposis), and difficulty latching on which can affect weight gain and long-term breastfeeding.

Updated October 20, 2017. Information about Zika virus is evolving. For additional information, see www.aap.org/zika or e-mail DisasterReady@aap.org

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