Infants & Children
Additional Considerations for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection
Infant Zika Evaluation and Management
- Comprehensive physical exam
- Head ultrasound
- Standard newborn hearing assessment
- Zika virus laboratory testing†
Possible Limitations of Infant Laboratory Testing
- The clinical findings are due to another cause
- Testing was incomplete (e.g., RNA testing without antibody testing), performed on suboptimal specimens (e.g., cord blood rather than blood obtained from the infant), or performed too late (e.g., after RNA and IgM antibodies had cleared or waned) (4)
- The fetus failed to mount an IgM antibody response; it is unknown if some fetuses infected early in gestation might not mount an IgM antibody response (5)
New Considerations for Evaluation of Infants with Possible Congenital Zika Virus Infection
Testing of cerebrospinal fluid (CSF)
Testing of infants whose mothers have possible Zika virus exposure during pregnancy but were not tested or were tested more than 12 weeks after maternal exposure or symptoms
- Infants born to mothers with an epidemiologic link§ to an area with risk of Zika and a CDC travel notice and for whom maternal testing was not performed before delivery or was performed more than 12 weeks after maternal exposure should have a comprehensive physical examination, including standardized measurement of head circumference.
- Maternal diagnostic testing should be performed if exposure is within the last 12 weeks¶, and testing of the placenta for Zika virus PCR should be considered.
- Infant testing should be performed if maternal testing is consistent with laboratory evidence of Zika virus infection.
- If an infant appears clinically well, further evaluation, including head ultrasound and infant laboratory Zika virus testing, can be deferred until maternal test results are available.
- If there is concern about infant follow-up or maternal testing is not performed or negative in the setting of an exposure that occurred more than 12 weeks earlier, head ultrasound, ophthalmologic assessment, and infant Zika virus testing should be considered before hospital discharge.
Testing beyond 2 days of life
Maintain a level of suspicion
- Evaluate for other causes of congenital infection
- Consider an ophthalmology exam and auditory brainstem response (ABR) hearing test before hospital discharge or within 1 month of birth
- Consider performing other evaluation and follow up in accordance with CDC interim guidance for the evaluation and management of infants with possible congenital Zika virus infection
† Infant serum and urine should be tested for Zika virus by Zika NAT, and infant serum for Zika virus IgM antibodies. If CSF is obtained, it can also be tested. If the mother has not been tested, infant specimens that are IgM positive should be confirmed by PRNT. Specimen collection should ideally be performed within the first 2 days after birth.
§ An epidemiologic link includes travel to or residence in an area with risk of Zika or sex without a condom with a partner who traveled to or lived in such an area.
¶For pregnant women with possible Zika virus exposure who seek care >12 weeks after symptom onset or possible exposure, IgM antibody testing might be considered. However, a negative IgM antibody test or rRT-PCR result >12 weeks after symptom onset or possible exposure does not rule out recent Zika virus infection because IgM antibody and viral RNA levels decline over time.
- Russell K, Oliver SE, Lewis L, Barfield WD, Cragan J, Meaney-Delman D, Staples JE, Fischer M, Peacock G, Oduyebo T, Petersen EE, Zaki S, Moore CA, Rasmussen SA; Contributors. Update: Interim guidance for the evaluation and management of infants with possible congenital Zika virus infection — United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65(33):870–878
- Melo AS, Aguiar RS, Amorim MM, Arruda MB, Melo FO, Ribeiro ST, Batista AG, Ferreira T, Dos Santos MP, Sampaio VV, Moura SR, Rabello LP, Gonzaga CE, Malinger G, Ximenes R, de Oliveira-Szejnfeld PS, Tovar-Moll F, Chimelli L, Silveira PP, Delvechio R, Higa L, Campanati L, Nogueira RM, Filippis AM, Szejnfeld J, Voloch CM, Ferreira OC Jr, Brindeiro RM, Tanuri A. Congenital Zika virus infection: Beyond neonatal microcephaly. JAMA Neurol 2016;73(12):1407–1416.
- de Araujo TV, Rodrigues LC, de Alencar Ximenes RA, de Barros Miranda-Filho D, Montarroyos UR, de Melo AP, et al. Association between Zika virus infection and microcephaly in Brazil, January to May, 2016: Preliminary report of a case-control study. Lancet Infect Dis 2016;16(12):1356–1363.
- Honein MA, Dawson AL, Petersen EE, Jones AM, Lee EH, Yazdy MM, et al. Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy. JAMA 2017;317(1):59–68.
- Alford CA, Foft JW, Blankenship WJ, Cassady G, Benton JW. Subclinical central nervous system disease of neonates: A prospective study of infants born with increased levels of IgM. J Pediatr 1969;75:1167–1178.