Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3),. 288-295.
CONFLICTS OF INTEREST STATEMENT • I HAVE NO FINANCIAL CONFLICTS OF INTEREST TO DECLARE. • I HAVE NO OTHER CONFLICTS OF INTEREST TO DECLARE.
LEARNING OBJECTIVES • AT THE END OF THIS SESSION, PARTICIPANTS WILL BE ABLE TO:
• CHARACTERIZE THE POPULATION OF INFANTS MOST AT RISK FOR CONGENITAL ZIKA SYNDROME • IDENTIFY THE 5 SIGNS AND CONDITIONS INDICATIVE OF CONGENITAL ZIKA SYNDROME • STATE THE APPROPRIATE COURSES OF ACTION FOR HEALTH PROFESSIONALS TO TAKE REGARDING INFANTS AT RISK OR AFFECTED BY ZIKA
OUTLINE • CHARACTERISTICS OF POPULATION OF INFANTS MOST AT RISK FOR CONGENITAL ZIKA SYNDROME • SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • MANAGEMENT OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION
CHARACTERISTICS OF POPULATION OF INFANTS MOST AT RISK FOR CONGENITAL ZIKA SYNDROME
• FROM NATIONWIDE CDC STUDY • DATA FROM JANUARY 15 TO DECEMBER 2016 • N = 1297 PREGNANCIES WITH ANY LAB EVIDENCE OF POSSIBLE ZIKA VIRUS INFECTION (CONFIRMED OR SUSPECTED)
• OF THOSE, 972 COMPLETED PREGNANCIES • OF THOSE, 51 ABNORMALITIES (43 BRAIN DEFECTS AND/OR MICROCEPHALY, 8 WITH OTHER BIRTH DEFECTS BUT NO BRAIN DEFECTS OR MICROCEPHALY)
CHARACTERISTICS OF POPULATION OF INFANTS MOST AT RISK FOR CONGENITAL ZIKA SYNDROME • AMONG 972 COMPLETED PREGNANCIES WITH ANY LAB EVIDENCE OF ZIKA, 5% HAD ZIKA-RELATED BIRTH DEFECTS (95% CI 4-7%)
• AMONG 250 COMPLETED PREGNANCIES WITH LAB-CONFIRMED EVIDENCE OF ZIKA, 10% HAD ZIKARELATED BIRTH DEFECTS (95% CI 7-14%)
• THOSE WITH LAB-CONFIRMED EVIDENCE WERE SIGNIFICANTLY MORE LIKELY TO HAVE BIRTH DEFECTS (EVIDENCE IN FAVOR OF ASSOCIATION BETWEEN ZIKA AND RELATED DEFECTS)
• THE PROPORTION OF FETUSES AND INFANTS WITH ZIKA VIRUS–ASSOCIATED BIRTH DEFECTS WAS HIGHEST AMONG THOSE WITH FIRST TRIMESTER ZIKA VIRUS INFECTIONS (15%, 95% CI 8-26%)
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • SEVERE MICROCEPHALY (SMALL HEAD SIZE) RESULTING IN A PARTIALLY COLLAPSED SKULL • DECREASED BRAIN TISSUE WITH CHARACTERISTIC BRAIN DAMAGE (AS INDICATED BY A SPECIFIC PATTERN OF CALCIUM DEPOSITS)
• DAMAGE TO THE BACK OF THE EYE WITH A SPECIFIC PATTERN OF SCARRING AND INCREASED PIGMENT • LIMITED RANGE OF JOINT MOTION, SUCH AS CLUBFOOT • EXCESSIVE MUSCLE TONE RESTRICTING BODY MOVEMENT SOON AFTER BIRTH
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • SEVERE MICROCEPHALY (SMALL HEAD SIZE) RESULTING IN A PARTIALLY COLLAPSED SKULL
Moore, C. A., Staples, J. E., Dobyns, W. B., Pessoa, A., Ventura, C. V., Da Fonseca, E. B., ... & Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3), 288-295.
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • SMALLER THAN NORMAL HEAD SIZE FOR AGE AND SEX • HEAD SIZE CORRELATES WITH UNDERLYING BRAIN SIZE • THESE MEASUREMENTS DO NOT CONSISTENTLY PREDICT LONG TERM SEQUELAE • NEUROLOGIC SEQUELAE MAY INCLUDE SEIZURES, VISION OR HEARING PROBLEMS, AND DEVELOPMENTAL DISABILITIES. SYMPTOMS VARY WITH THE EXTENT OF BRAIN DISRUPTION.
• ZIKA VIRUS INFECTION DURING PREGNANCY IS A CAUSE OF MICROCEPHALY. • UNCLEAR IF A NEWBORN WHO GETS ZIKA VIRUS INFECTION AROUND THE TIME OF BIRTH WILL DEVELOP MICROCEPHALY AFTER BIRTH
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • DECREASED BRAIN TISSUE WITH SPECIFIC PATTERNS OF BRAIN DAMAGE, INCLUDING SUBCORTICAL CALCIFICATION Moore, C. A., Staples, J. E., Dobyns, W. B., Pessoa, A., Ventura, C. V., Da Fonseca, E. B., ... & Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3), 288-295.
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • DAMAGE TO THE BACK OF THE EYE, INCLUDING MACULAR SCARRING AND FOCAL PIGMENTARY RETINAL MOTTLING Moore, C. A., Staples, J. E., Dobyns, W. B., Pessoa, A., Ventura, C. V., Da Fonseca, E. B., ... & Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3), 288-295.
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME • CONGENITAL CONTRACTURES, SUCH AS CLUBFOOT
Moore, C. A., Staples, J. E., Dobyns, W. B., Pessoa, A., Ventura, C. V., Da Fonseca, E. B., ... & Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3), 288-295.
SIGNS AND CONDITIONS ASSOCIATED WITH CONGENITAL ZIKA SYNDROME •
HYPERTONIA OR HYPOTONIA AND OTHER NEUROLOGICAL PROBLEMS RESTRICTING BODY MOVEMENT SOON AFTER BIRTH Moore, C. A., Staples, J. E., Dobyns, W. B., Pessoa, A., Ventura, C. V., Da Fonseca, E. B., ... & Rasmussen, S. A. (2017). Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA pediatrics, 171(3), 288-295.
EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • SAME CDC STUDY ON 1297 PREGNANCIES • AMONG 895 LIVE BORN INFANTS FROM PREGNANCIES WITH POSSIBLE RECENT ZIKA VIRUS INFECTION, POSTNATAL NEUROIMAGING WAS REPORTED FOR ONLY 221 (25%)
• ZIKA VIRUS TESTING OF AT LEAST ONE INFANT SPECIMEN WAS REPORTED FOR 585 (65%).
EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • FOR INFANTS BORN FROM MOTHERS WHO DO NOT HAVE LAB EVIDENCE OF ZIKA BUT ARE AT ON-GOING RISK, APPROACH IS THE SAME EXCEPT: HEAD ULTRASOUND, OPHTHALMOLOGICAL ASSESSMENT, AND ZIKA LAB TEST AT THE DISCRETION OF THE CLINICIAN
• A HEAD ULTRASOUND IS RECOMMENDED BEFORE HOSPITAL DISCHARGE OR WITHIN 1 MONTH OF BIRTH FOR INFANTS WITH POSSIBLE ZIKA VIRUS INFECTION.
• OTHERWISE NOT ROUTINELY RECOMMENDED
EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • WHICH INFANTS SHOULD GET TESTED?
• INFANTS BORN TO MOTHERS WITH LAB EVIDENCE OF ZIKA VIRUS INFECTION DURING PREGNANCY • INFANTS WHO HAVE ABNORMAL CLINICAL FINDINGS SUGGESTIVE OF CONGENITAL ZIKA VIRUS SYNDROME AND A MATERNAL EPIDEMIOLOGIC LINK SUGGESTING POSSIBLE EXPOSURE DURING PREGNANCY, REGARDLESS OF MATERNAL ZIKA VIRUS TEST RESULTS.
•
BECAUSE MATERNAL TEST RESULTS CAN BE FALSELY NEGATIVE
EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • INTERPRETATION OF INFANT TEST RESULTS
EVALUATION AND TESTING OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • POST NATAL ZIKA VIRUS INFECTION SHOULD BE SUSPECTED IN INFANTS AND CHILDREN IF THEY MEET THE SAME CRITERIA AS FOR ADULTS:
• TRAVEL TO OR RESIDENCE IN AN AREA AT RISK FOR ZIKA (OR IN SOME CASES EXPOSURE THROUGH SEXUAL CONTACT WITH SOMEONE FROM SUCH AN AREA), AND
• 2 OUT OF THE 4 MAIN SYMPTOMS OF ZIKA VIRUS DISEASE: FEVER, ARTHRALGIA, CONJUNCTIVITIS, AND RASH
MANAGEMENT OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION • THE PROGNOSIS FOR INFANTS WITH CONGENITAL ZIKA VIRUS INFECTION IS CURRENTLY UNKNOWN. • FOR INFANTS WITH CONGENITAL ZIKA VIRUS INFECTION, CARE IS FOCUSED ON: • DIAGNOSING AND MANAGING CONDITIONS THAT ARE PRESENT • MONITORING THE CHILD’S DEVELOPMENT OVER TIME, AND • ADDRESSING PROBLEMS AS THEY ARISE.
Outpatient management checklist
MANAGEMENT OF INFANTS AFFECTED OR SUSPECTED OF NEONATAL ZIKA INFECTION
Infant with abnormalities consistent with congenital Zika syndrome and laboratory evidence of Zika virus infection
2 weeks
1 mo.
Thyroid screen (TSH & free T4)
Neuro exam Neuro exam Thyroid screen (TSH & free T4) Ophthalmology exam
Infant with abnormalities consistent with congenital Zika syndrome and negative for Zika virus infection
2 mo.
3 mo.
4-6 mo.
9 mo.
Repeat audiology evaluation (ABR)
Developmental screening
12 mo.
Routine preventive health care including monitoring of feeding, growth, and development Routine and congenital infection-specific anticipatory guidance Referral to specialists as needed Referral to early intervention services
Evaluate for other causes of congenital anomalies Further management as clinically indicated
Infant with no abnormalities consistent Ophthalmology exam with congenital Zika syndrome and ABR laboratory evidence of Zika virus infection
Consider repeat ABR
Developmental screening Behavioral audiology evaluation if ABR was not done at 4-6 mo
Monitoring of growth parameters (Head circumference, weight, and height), developmental monitoring by caregivers and health care providers, and age-appropriate developmental screening at well-child visits Infant with no abnormalities consistent with congenital Zika syndrome and Monitoring of growth parameters (Head circumference, weight, and height), developmental monitoring by caregivers and negative for Zika virus infection health care providers, and age-appropriate developmental screening at well-child visits
USEFUL CLINICAL RESOURCES • ROADMAP FOR PARENTS OF NEWBORNS WITH CONGENITAL ZIKA SYNDROME: HTTPS://WWW.CDC.GOV/ZIKA/PARENTS/CARE-FOR-BABIES-WITH-CONGENITAL-ZIKA.HTML
• VIDEO ON HOW TO MEASURE HEAD CIRCUMFERENCE FOR MICROCEPHALY: HTTPS://WWW.YOUTUBE.COM/WATCH?V=HWV1JDAHSSO
TEST YOUR KNOWLEDGE! • WHAT PROPORTION OF INFANTS BORN FROM MOTHERS WITH ANY LAB EVIDENCE OF ZIKA HAVE CONGENITAL ZIKA-RELATED DEFECTS?
• 5%
• WHAT PROPORTION OF INFANTS BORN FROM MOTHERS WITH CONFIRMED LAB EVIDENCE OF ZIKA HAVE ZIKA-RELATED CONGENITAL DEFECTS?
• 10%
TEST YOUR KNOWLEDGE! • WHAT ARE THE 5 SIGNS, SYMPTOMS AND CONDITIONS THAT ARE CONSIDERED TO BE ZIKA-RELATED CONGENITAL DEFECTS?
• MICROCEPHALY, BRAIN CALCIFICATIONS, EYE ABNORMALITIES, HYPERTONIA, CONTRACTURES
• WHAT IS THE MOST IMPORTANT RISK FACTOR KNOWN TO BE ASSOCIATED WITH ZIKA-RELATED CONGENITAL BIRTH DEFECTS?
• EXPOSURE DURING 1ST TRIMESTER
SUMMARY: KEY POINTS • APPROXIMATELY ONE IN 10 PREGNANCIES WITH LABORATORY-CONFIRMED ZIKA VIRUS INFECTION RESULTED IN A FETUS OR INFANT WITH ZIKA VIRUS–ASSOCIATED BIRTH DEFECTS.
• THE PROPORTION OF FETUSES AND INFANTS WITH ZIKA VIRUS–ASSOCIATED BIRTH DEFECTS WAS HIGHEST AMONG THOSE WITH FIRST TRIMESTER ZIKA VIRUS INFECTIONS.
SUMMARY: KEY POINTS • ONLY 25% OF INFANTS FROM PREGNANCIES WITH POSSIBLE RECENT ZIKA VIRUS INFECTION REPORTEDLY RECEIVED POSTNATAL NEUROIMAGING.
• IDENTIFICATION AND FOLLOW-UP CARE OF INFANTS BORN TO MOTHERS WITH LABORATORY EVIDENCE OF POSSIBLE RECENT ZIKA VIRUS INFECTION DURING PREGNANCY AND INFANTS WITH CONGENITAL ZIKA VIRUS INFECTION CAN ENSURE THAT APPROPRIATE INTERVENTION SERVICES ARE AVAILABLE TO AFFECTED INFANTS.
SOURCES • VITAL SIGNS: UPDATE ON ZIKA VIRUS–ASSOCIATED BIRTH DEFECTS AND EVALUATION OF ALL U.S. INFANTS WITH CONGENITAL ZIKA VIRUS EXPOSURE — U.S. ZIKA PREGNANCY REGISTRY, 2016. APRIL 7, 2017. HTTPS://WWW.CDC.GOV/MMWR/VOLUMES/66/WR/MM6613E1.HTM?S_CID=MM6613E1_W
• UPDATE: INTERIM GUIDANCE FOR HEALTH CARE PROVIDERS CARING FOR PREGNANT WOMEN WITH POSSIBLE ZIKA VIRUS EXPOSURE — UNITED STATES (INCLUDING U.S. TERRITORIES), JULY 2017. JULY 24, 2017. HTTPS://WWW.CDC.GOV/MMWR/VOLUMES/66/WR/MM6629E1.HTM
• CONGENITAL ZIKA VIRUS INFECTION: EVALUATION AND TESTING. AUGUST 14, 2017. HTTPS://WWW.CDC.GOV/ZIKA/HC-PROVIDERS/INFANTS-CHILDREN/EVALUATION-TESTING.HTML
SOURCES • CONGENITAL ZIKA SYNDROME AND OTHER BIRTH DEFECTS. AUGUST 9, 2017. HTTPS://WWW.CDC.GOV/ZIKA/HC-PROVIDERS/INFANTS-CHILDREN/ZIKA-SYNDROME-BIRTH-DEFECTS.HTML
• ZIKA IN INFANTS AND CHILDREN. APRIL 27, 2017. HTTPS://WWW.CDC.GOV/ZIKA/HC-PROVIDERS/INFANTSCHILDREN/ZIKA-IN-INFANTS-CHILDREN.HTML
• FOLLOW-UP CARE. JUNE 5, 2017. HTTPS://WWW.CDC.GOV/ZIKA/HC-PROVIDERS/INFANTSCHILDREN/FOLLOW-UP-CARE.HTML
• MOORE, CYNTHIA A., ET AL. "CHARACTERIZING THE PATTERN OF ANOMALIES IN CONGENITAL ZIKA SYNDROME FOR PEDIATRIC CLINICIANS." JAMA PEDIATRICS 171.3 (2017): 288-295.
