ATLANTA -- Children with Zika virus infection will need multidisciplinary care in a medical home environment led by their primary care pediatrician, according to a series of recommendations presented by pediatric experts here.
The primary care provider will optimize and potentially coordinate communication between pediatric subspecialists, as well as act as the child's regular pediatrician. Monthly visits are recommended, where the child's growth parameters will be checked through 6 months of age, and the child will receive the regular schedule of pediatric immunizations.
"The primary care provider needs to stay involved with what is going on, continue to monitor growth development and during subspecialty care, even after referrals are made," said Janet Cragan, MD, of the CDC, at the discussion.
Developmental screening will also be essential at each pediatric visit. A full neurologic exam, such as the Dubowitz, at ages 1 and 2 months is recommended. Because infant seizures, which are associated with congenital Zika infection, can be subtle, clinicians may need to be educated on how to identify them so they can advise caregivers.
"Many providers have never actually seen this type of seizures, so we really need some education on what to look for to identify seizure activity that is not overt," added Cragan.
Other screenings include vision, hearing and endocrine, as well as observing infant feeding for abnormal sucking, which may lead to aspiration or gastroesophageal reflux.
Family support is also crucial in caring for infants with Zika, and CDC researchers described the care plan for these children as "family-centered" and "family-guided." In addition to receiving guidance from the provider, psychosocial support is also recommended for families -- especially referrals to community resources for support.
Close Follow-Up for Asymptomatic Children
Family support and engagement, as well as development, vision and hearing screening were the key components for pediatricians treating children with Zika virus exposure or risk factors, but who do not test positive for Zika.
Because symptoms of Zika may not manifest until later in a child's development, anticipatory guidance for the family about developmental milestones, feeding and growth patterns, and potential issues that may develop with sleep and irritability.
"There is the potential for seizures to develop over time, so it's important to ask about abnormal movements and staring, as that might be of concern for seizures," said Kate Russell, MD, of Duke University. "This is an area of very new research and growing literature, so this will be a continuous process."
The child would also receive an eye exam at each visit, as well as the potential to repeat a hearing test, even if infants passed the newborn screening. If a child fails either a vision test or a hearing test, this should prompt a referral to both an ophthalmologist and an audiologist.
Standardized validated screening tools would be used at 9 months, as currently recommended by the American Academy of Pediatrics, but would be employed earlier if any concerns are raised by the parent or provider.
Of course, the point where the line between an asymptomatic and a symptomatic infant may be difficult to distinguish by the provider.
"It's going to fall on the front lines of the families bringing up their concerns and the PCPs who see the patients," said a pediatric infectious disease specialist, commenting on how providers will draw the line between when a child crosses over into being treated for active Zika virus infection.
One participant said that since additional screenings will likely uncover additional issues, there will also be a number of issues to providers about what to disclose and not to disclose to the parents, especially during newborn screening.
"We need to understand what this really means for families and what the level of risk really is," he said. "There probably is a much greater risk than we thought, but we don't have any clue about the magnitude of it."
Transfer Symptomatic Infants to Tertiary Care Facilities
While the most guidance currently exists on how to treat newborns born with symptomatic Zika virus infection, pediatricians seemed to agree that a consideration of transfer should be given so the newborn can receive treatment in a facility with access to pediatric subspecialty care.
But the question arose about where to draw that line for prenatal care -- for example, if a mother tests positive, but the ultrasound does not show signs of fetal brain disruption. The concern was that if the child was relatively asymptomatic, families may be separated unnecessarily.
"I think it's better to deliver where the mother feels comfortable and make sure supports are in place for the family," said Georgina Peacock, MD, of the CDC. "Suddenly transferring to a tertiary care center delivers the message that this is serious."
But Philip Heine, MD, of Duke, seemed to disagree. "Any mother who tests positive will be referred to tertiary care center," he contended.
Other recommendations currently in discussion are how to test the newborn for Zika infection at birth. There will likely be PCR and IgM testing on infant specimens, such as cerebrospinal fluid if there is concern about neurologic findings.
The infant should also receive a cranial ultrasound, as the antenatal ultrasound may not be adequate to detect certain abnormalities.
Finally, the CDC has, so far at least, decided to stick with standard precautions for healthcare personnel in terms of handling bodily fluids, despite the recent case of Zika infection that may have occurred through person-to-person contact.
These pediatric expert groups will hold one more discussion among their peers before they refine the new recommendations. When finalized, they will likely be released by the CDC with publication in Morbidity and Mortality Weekly Report.