New interim guidance from The Centers for Disease Control and Prevention (CDC) emphasizes the need for standard screening and monitoring of infants with possible congenital Zika virus infection plus hearing screening and specific testing and evaluation in three clinical scenarios. The recommendations were published in MMWR and are based on available data on Zika virus infection and interpretation of individual expert opinion collected during a Forum on the Diagnosis, Evaluation and Management of Zika Virus Infection Among Infants held by CDC in August in collaboration with the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.
The guidance follows publication of clinical data on: (1) eye findings in infants without microcephaly or other brain anomalies whose mothers have laboratory evidence of Zika; (2) later development of microcephaly in infants born with normal head circumferences; development of hydrocephalus in infants born with microcephaly; (3) abnormalities on sleep electroencephalogram (EEG) in some infants with microcephaly who did not have recognized seizures; and (4) diaphragmatic paralysis in infants born with microcephaly and arthrogryposis.
For infants with clinical findings consistent with congenital Zika syndrome born to mothers with possible Zika virus exposure in pregnancy, CDC recommends a standard evaluation at birth plus a head ultrasound and a comprehensive ophthalmologic exam. The latter should be performed by age 1 month by an ophthalmologist experienced in assessment of and intervention in infants. For newborns who pass a hearing screening using only otoacoustic emissions methodology, a referral should be made for an automated auditory brain stem response (ABR) test by age 1 month. Referrals to a developmental specialist and early intervention services programs also are recommended.
The CDC report said that for infants with clinical findings consistent with congenital Zika syndrome, consultations also should be considered with:
- Infectious Disease for evaluation of other congenital infections and assistance with Zika virus diagnosis, testing, and counseling;
- Clinical Genetics for confirmation of the clinical phenotype and evaluation for other causes of microcephaly or congenital anomalies; and
- Neurology by age 1 month for comprehensive neurologic examination and consideration for other evaluations, such as advanced neuroimaging and EEG.
For infants without clinical findings consistent with congenital Zika syndrome born to mothers with laboratory evidence of possible Zika virus infection during pregnancy, CDC recommends the following:
- Zika virus testing;
- Standard evaluation plus a head ultrasound and comprehensive ophthalmologic exam by age 1 month and referral for an ABR by age 1 month if an infant passed a hearing screening using only otoacoustic emissions methodology; and
- Vigilant follow-up at well-child visits for signs of congenital Zika virus infection.
For infants with no clinical evidence of Zika Syndrome born to mothers with laboratory evidence of possible Zika virus infection during pregnancy, a diagnostic ABR at 4 to 6 months or behavioral audiology at 9 months is no longer recommended if the initial hearing screening was passed by automated ABR because of absence of data suggesting delayed-onset