Brief Reports
November 15, 1999 4 minutes read
Brief Reports
Varicella Zoster Immunoglobulin may not Prevent Severe Neonatal Varicella
Source: Reynolds L, et al. Neonatal varicella: Varicella zoster immunoglobulin (VZIG) does not prevent disease. Arch Dis Child Fetal Neonatol Ed 1999;81:69-70.
As many as 50% of infants born to mothers who develop chickenpox four or fewer days before delivery and up to two days after delivery develop clinical varicella. In these clinically infected newborns, the fatality rate is as high as 31% if no prophylaxis or therapy is given. The use of varicella zoster immunoglobulin (VZIG) can modify the clinical course and usually prevents more serious neonatal disease. However, although decreased, the risk of fatality is not totally eliminated.
Reynolds and associates from the St. Mary’s Hospital Medical School in London describe two Asian newborns with severe neonatal varicella infections. One of the mothers developed chickenpox two days before delivery; the other one day after delivery. Both infants received intramuscular VZIG in the first day of life, but no information concerning further care or follow-up was apparently given to the families or out-of-hospital health care providers. At 10 and 11 days of life, the infants developed severe disease requiring ventilatory support. Intravenous acyclovir was administered for 2-3 weeks. Both babies recovered after a stormy hospital course.
In each of these patients, there was a three-day delay between the onset of symptoms and the institution of antiviral therapy with acyclovir, a delay resulting from an apparent lack of awareness of the risk of varicella in the infants despite appropriate therapy with VZIG. The average interval between the onset of the mother’s rash to the baby’s rash in untreated cases is 11 days. However, administration of VZIG to the newborn baby can prolong the incubation period to as long as 30 days.
When a neonate has received VZIG because of maternal perinatal chickenpox, it should be made clear to the parents and health workers that if the baby becomes sick or develops any kind of a rash, the child should be seen and hospitalization for prompt institution of acyclovir therapy should be strongly considered to prevent avoidable morbidity and even mortality. Even the 1997 AAP Red Book is less than definitive on this point. VZIG (125 U) is recommended for infants whose mothers have the onset of varicella from five days before to two days after delivery. Approximately half of these newborns can be expected to develop varicella even if VZIG is administered, but "the disease is often modified. Nevertheless VZIG recipients should be followed closely." —lmb
Which of the following is correct?
a. Infants born to mothers who develop chickenpox during a period of several days before to several days after delivery have an approximately 5% chance of developing clinical varicella infection.
b. The fatality rate of untreated neonatal varicella infection is almost 100%.
c. The administration of varicella zoster immune globulin (VZIG) to infants exposed perinatally to varicella reduced their risk of developing clinical varicella by approximately 50%.
d. The incubation period of neonatal varicella is shortened by the administration of VZIG.
Infrequency of Serious Infections in Infants Younger than 8 Weeks with Otitis Media
Source: Nozicka CA, et al. Otitis media in infants aged 0-8 weeks: Frequency of associated serious bacterial disease. Pediatr Emerg Care 1999;15:252-254.
Nozicka and associates at the children’s hospital of Wisconsin emergency department (ED) in Milwaukee studied 40 nontoxic-appearing small infants with otitis media (OM) confirmed by a pediatric otolaryngologist using a binocular operating microscope. Thirty-eight percent (15/40) had rectal temperatures equal to or greater than 38°C. All infants had typanocentesis with middle ear fluid (MEF) culture and complete sepsis evaluation including CBC, blood culture, catheter urine culture, and lumbar puncture with cerebrospinal fluid (CSF) culture. All infants were treated with parenteral ampicillin and either gentamicin or cefotaxime and admitted to the hospital.
Bacterial pathogens were recovered from the MEF in 25/40 (62.5%) infants, and 15 infants had negative cultures of the MEF. All infants who were afebrile on admission to the ED had negative blood, urine, and CSF cultures. Only two of 15 febrile infants had positive cultures from sites other than the MEF.
Nozicka et al conclude that previously healthy, nontoxic-appearing afebrile, nontoxic infants aged 2-8 weeks of age with otitis media infrequently have an associated serious bacterial infection and the oral antibiotic therapy with close follow-up may be a reasonable therapeutic option. However, infants younger than 2 months of age with OM who are febrile, toxic, or who have signs of systemic illness require a full septic workup and consideration of parenteral antibiotic therapy. —lmb (Dr. Bell is Associate Professor of Pediatrics [Infectious Diseases], University of Pennsylvania School of Medicine, Philadelphia, PA.)
Neonates with proven otitis media:
a. frequently have bacterial pathogens cultured from MEF.
b. frequently have bacterial pathogens cultured from other sites than the MEF.
c. have other positive bacterial cultures more frequently if they are febrile/toxic.
d. should always be hospitalized for a septic workup and parenteral antibiotics.
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