Functioning and Disability Profile of Children with Microcephaly Associated with Congenital Zika Virus Infection

Virus as Teratogenic Agents

Viral infectious diseases are important causes of reproductive disorders, as abortion, fetal mummification, embryonic mortality, stillbirth, and congenital abnormalities in animals and in humans. In this chapter, we provide an overview of some virus, as important agents in teratology.We begin by describing the Zika virus, whose infection in humans had a very significant impact in recent years and has been associated with major health problems worldwide. This virus is a teratogenic agent in humans and has been classified as a public health emergency of international concern (PHEIC).Then, some viruses associated with reproductive abnormalities on animals, which have a significant economic impact on livestock, are described, as bovine herpesvirus, bovine viral diarrhea virus, Schmallenberg virus, Akabane virus, and Aino virus.For all viruses mentioned in this chapter, the teratogenic effects and the congenital malformations associated with fetus and newborn are described, according to the most recent scientific publications.

Rehabilitation Practices Delivered by Physical and Occupational Therapists to Brazilian Children With Congenital Zika Syndrome: A Cross-Sectional Study

INTRODUCTION

Congenital Zika syndrome (CZS) is a health condition that has affected the development of thousands of children in Brazil. Because it is a new condition, its understanding is an ongoing process. Therefore, it is important to know the rehabilitation interventions being delivered to improve the functioning of these children. We aimed to describe the practices of physical therapists (PTs) and occupational therapists (OTs) who provide follow-up care for children with CZS in Brazil.

METHODS

This cross-sectional study included PTs and OTs who assist children with CZS in Brazil. An online questionnaire was used to verify the participants' personal characteristics and professional work environment, as well as the rehabilitation programs they implemented in Brazil for children with CZS. Data were analyzed using descriptive statistics.

RESULTS

A total of 116 professionals (79 PT and 37 OT) who work mainly in public health services (81.9%) participated in the study. Of these, 24.1% plan interventions based on reading scientific articles, 66.4% did not report using the biopsychosocial model, 52.6% do not perform any assessments before starting an intervention, 31.9% use neurodevelopmental treatment, and 22.4% use sensorimotor stimulation interventions. The majority of the interventions are delivered 1 to 2 times a week, lasting up to 1 hour.

CONCLUSIONS

Professional training and knowledge translation strategies are needed to implement evidence-based practices and improve the quality of rehabilitation programs for Brazilian children with CZS.

Predictors of Neurodevelopment in Microcephaly Associated with Congenital Zika Syndrome: A Prospective Study

The municipality of Salvador, situated in Brazil, distinguished itself as the epicenter of the emergence of microcephaly related to congenital manifestations of Zika syndrome. Despite the anticipated significant developmental setbacks in these children, research has indicated a varied range of outcomes, with certain instances even reflecting minimal developmental delay. Our objective was to pinpoint determinants that could forecast developmental anomalies in children diagnosed with microcephaly associated with congenital Zika syndrome (CZS).

METHODOLOGY

A forward-looking clinical and neurodevelopmental examination was conducted focusing on neonates diagnosed with microcephaly with CZS, birthed between September 2015 and April 2016 at the Hospital Geral Roberto Santos, in Salvador city. That infants were monitored up to their third year by a multiprofessional team. Child development was assessed using the composite Bayley III score. Undertaken by two blinded experts, cranial CT scan analysis was performed during the neonate period for the detection of brain abnormalities and to quantify ventricle enlargement, measured by Evans' index (EI).

RESULTS

Fifty newborns were evaluated with a median head circumference of 28 cm (interquartile range 27-31 cm). EI was associated with neurodevelopmental delay at three years and remained significant after adjustment for head circumference. A 0.1-point increase in EI was associated with a delay of 3.2 months in the receptive language (p = 0.016), 3.4 months in the expressive language (p = 0.016), 3.4 months in the cognitive (p = 0.016), 2.37 months in the gross motor (p = 0.026), and 3.1 months in the fine motor (p = 0.021) domains.

CONCLUSIONS

EI predicted neurodevelopmental delay in all Bayley domains in children with microcephaly associated with CZS.

Change in functioning profile after cervical surgery

The objectives are to (a) introduce an approach to use the Neck Disability Index (NDI) in a way, which is different and more International Classification of Functioning, Disability and Health-oriented than acommon practice - focusing on functional profile instead of composite score only, and (b) to describe the changes in functioning experienced by patients undergoing cervical surgery. This was a register-based study of almost 400 patients undergoing different cervical surgical procedures in a university hospital between 2018 and 2021. The patients responded to repeated surveys preoperatively and 3, 12 and 24 months postoperatively. Linear regression test was performed to analyze the change of the NDI score. The changes in scores during a follow-up were statistically significant ( P < 0.001) for all the NDI items as well as for the total score. Each item demonstrated significant improvement postoperatively and a slight worsening between 1 and 2 years after the surgery. The observed slight decline in functioning at the end of follow-up remained below the baseline level for all the items. While the change in the composite score of the NDI was able to describe the overall change in functioning after the surgery, different areas of functioning were affected by the surgery differently. The results suggest that the use of functional profiles, in addition to composite scores, is justified among patients with cervical pathologies.

Congenital Zika Syndrome and Disabilities of Feeding and Breastfeeding in Early Childhood: A Systematic Review

Background: The Zika virus outbreak has affected pregnant women and their infants. Affected infants develop microcephaly and other congenital malformations referred to as congenital Zika syndrome. The neurological manifestations of congenital Zika syndrome may result in some feeding disorders, including dysphagia, swallowing dysfunction and choking while feeding. The aim of this study was to assess the prevalence of feeding and breastfeeding difficulties in children with congenital Zika syndrome and to estimate the risk of developing feeding disabilities. Methods: We searched PubMed, Google Scholar and Scopus for studies published from 2017 to 2021. From the total of 360 papers, reviews, systematic reviews, meta-analyses and publications in languages other than English were excluded. Therefore, the final sample of our study consisted of 11 articles about the feeding/breastfeeding difficulties of infants and children with congenital Zika syndrome. Results: Infants and children with congenital Zika syndrome were likely to suffer from feeding difficulties at various levels, including breastfeeding. Dysphagia problems ranged from 17.9% to 70%, and nutritional and non-nutritive suckling of infants was also affected. Conclusions: In addition to continuing to investigate the neurodevelopment of affected children, future research should also focus on the severity of factors influencing the degree of dysphagia, as well as the impact of breastfeeding on the child’s overall development.

Burden in caregivers of children with congenital Zika syndrome in Pernambuco, Brazil: analysis and application of the Zarit burden interview scale

With the increase in cases of microcephaly caused by the Zika virus, the demand for special care and a better quality of life for the child and caregiver increased proportionally.

Objective

This study aimed to analyze the burden on caregivers of children with congenital Zika syndrome associated with viral infections in the state of Pernambuco, Brazil using the Zarit Burden interview scale.

Method

A quantitative study was conducted at the Oswaldo Cruz University Hospital, Recife City, State of Pernambuco, Brazil. By convenience sampling, 56 mothers, two grandmothers, and two caregivers were enrolled, all are female. Data were collected from July 2019 to January 2020. In the analysis, the percentage frequencies were calculated. The normality was identified using the Kolmogorov-Smirnov test, and participant profiles were compared using Student's t-test and analysis of variance. In descriptive statistics, quantitative variables are described by the median and interquartile range and categorical variables by proportions using the Chi-square test.

Results

In the comparative analysis, all factors evaluated were significant, except for the "gestational period in which the disease occurred" (p < 0.111). The significance of differences in all activities was evaluated. In the mean comparison test, only the factor "has a job" was significant (p < 0.043). When comparing the average of caregivers' responses to the categories of the Zarit burden interview scale, the highest level of burden was regarding the feeling that the child is dependent on the caregiver (3.62 points). Caregiver burden was classified as absence, light, moderate, and high.

Conclusion

The consequences of contracting the Zika virus in the first trimester of pregnancy, lack of paid work, financial scarcity, full-time dedication to the child, and lack of time for themselves increase the burden on caregivers. Thus, caregivers have mild burden.

Motor development of children exposed to the zika virus: systematic reviews

Abstract Objectives: to describe the motor development, in the first two years of life, of children with evidence of congenital Zika virus syndrome (CZS) at birth and of children exposed to the Zika virus (ZIKV) during pregnancy, but without evidence of CZS. Methods: systematic review, according to the recommendations of the Preferred Reporting Items for Systematic Reviews (PRISMA). The search took place in the VHL/LILACS interface and BIREME/ PubMed interface databases until March 2020. Two researchers analyzed the quality of the studies using the Johanna Briggs Institute methodology. Results: 21 articles were selected. Children with CZS have severe impairment of motor functions and a high prevalence of spastic cerebral palsy. At two years of life, most reached only early levels of motor development; with impaired vision, hearing, language, cognition, behavior, and social interaction. On the other hand, children exposed to ZIKV, but without evidence of CZS, are at lower risk, about 20% have late manifestations of delay and/or neurodevelopmental disorder. Variables associated with greater motor impairment are early maternal infection, preterm birth, lower head circumference, abnormal imaging, use of anticonvulsant, increasing age, arthrogryposis, epilepsy, deficits in vision, language, cognition, and lower income. Conclusion: Most children with CZS show severe motor impairment; a small part of those exposed to ZIKV, without evidence of the syndrome at birth, have alteration in neurodevelopment. Those children should be followed in the long-term, since some manifestations may occur belatedly.

Acquired Hip Dysplasia in Children with Congenital Zika Virus Infection in the First Four Years of Life

Acquired hip dysplasia has been described in children with cerebral palsy (CP); periodic surveillance is recommended in this population to prevent hip displacement and dislocation. Children with congenital zika syndrome (CZS) may present a spectrum of neurological impairments with changes in tonus, posture, and movement similar to children with CP. However, the relationship between CZS and hip dysplasia has not been characterized. In this prospective cohort study, we aimed to describe the occurrence of hip dysplasia in patients with CZS. Sixty-four children with CZS from 6 to 48 months of age were included and followed at a tertiary referral center in Rio de Janeiro, Brazil, with periodic radiologic and clinical hip assessments. Twenty-six (41%) patients were diagnosed with hip dysplasia during follow-up; mean age at diagnosis was 23 months. According to the Gross Motor Function Classification System (GMFCS), 58 (91%) patients had severe impairment (GMFCS IV and V) at the first evaluation. All patients with progression to hip dysplasia had microcephaly and were classified as GMFCS IV or V. Pain and functional limitation were reported by 22 (84%) caregivers of children with hip dysplasia. All patients were referred to specialized orthopedic care; eight (31%) underwent surgical treatment during follow-up. Our findings highlight the importance of implementing a hip surveillance program and improving access to orthopedic treatment for children with CZS in order to decrease the chances of dysplasia-related complications and improve quality of life.

Characterizing Disabilities in Preschool Aged Children with Congenital Zika Virus Syndrome with the ICF Model

Understanding functioning and disabilities in children with Congenital Zika Syndrome (CZS) is essential for health planning. We describe disabilities present in children with CZS followed in a reference hospital in Rio de Janeiro, Brazil, based on the biopsychosocial model of the International Classification of Functioning, Disability and Health (ICF). This was a cohort study of children >3 years of age with CZS. Disability was characterized through outcomes related to ICF components assessed via clinical and motor development evaluations. Among 50 children, with a median age of 40 months, 47 (94%) presented with severe impairment and 46 (92%) had microcephaly. Damage to the head and neck was found in most children, with abnormal central nervous system imaging universally present. Most children had cognitive impairment (92%), muscle tone problems (90%), and speech deficits (94%). We found movement limitations in all categories but more pervasively (80−94%), in postural transfers and displacements. The main environmental factors identified in the ICF model were the use of products or substances for personal consumption and access to health services. Children with CZS have extremely high rates of disability beyond aged 3 years, particularly regarding motor activity. ICF-based models can contribute to the assessment of health domains.

Participatory Visual Methods with caregivers of children with Congenital Zika Syndrome in Colombia: A case study

Background: This study explores the acceptability and feasibility of the use of two different Participatory Visual Methods (Participatory Video and Digital Storytelling) in gathering information on the experiences and perspectives of carers of children with Congenital Zika Syndrome within Colombia. Methods: Participatory Video was used to assess the impact of the Juntos parent-support intervention in the lives of carers, and Digital Storytelling was used to explore the healthcare access for these children. In-depth interviews were conducted to probe participants on their views of these methods. Results: One Participatory Video was produced and four Digital Stories. Of the initial eight caregivers who took part in the Participatory Video process, four completed both the Digital Storytelling process and an in-depth interview about their experiences. The main factors shaping participants' experiences related to the skills learned in making the videos, the feeling of collectiveness and the control over the processes. Conclusions: Women with children with Congenital Zika Syndrome have reported feeling marginalised and misunderstood in daily life. This case study found that Participatory Visual Methods is acceptable and feasible. Moreover, these approaches can support groups in different aspects, such as providing a space to share their stories creatively, hear others in similar situations as them and increase the feeling of community.

Longitudinal Follow-Up of Gross Motor Function in Children with Congenital Zika Virus Syndrome from a Cohort in Rio de Janeiro, Brazil

Knowledge of how congenital Zika syndrome (CZS) impacts motor development of children longitudinally is important to guide management. The objective of the present study was to describe the evolution of gross motor function in children with CZS in a Rio de Janeiro hospital. In children with CZS without arthrogryposis or other congenital osteoarticular malformations who were followed in a prospective cohort study, motor performance was evaluated at two timepoints using the Gross Motor Function Classification System (GMFCS) and the Gross Motor Function Measurement test (GMFM-88). Among 74 children, at the baseline evaluation, the median age was 13 (8–24) months, and on follow-up, 28 (24–48) months. According to GMFCS at the second timepoint, 6 children were classified as mild, 11 as moderate, and 57 as severe. In the GMFM-88 assessment, children in the severe group had a median score of 10.05 in the baseline evaluation and a follow-up score of 12.40, the moderate group had median scores of 25.60 and 29.60, and the mild group had median scores of 82.60 and 91.00, respectively. Although a small developmental improvement was observed, the motor impairment of children was mainly consistent with severe cerebral palsy. Baseline motor function assessments were predictive of prognosis.

Participatory Visual Methods with caregivers of children with Congenital Zika Syndrome in Colombia: A case study

Background: This study explores the acceptability and feasibility of the use of two different Participatory Visual Methods (Participatory Video and Digital Storytelling) in gathering information on the experiences and perspectives of carers of children with Congenital Zika Syndrome within Colombia. Methods: Participatory Video was used to assess the impact of the Juntos parent-support intervention in the lives of carers, and Digital Storytelling was used to explore the healthcare access for these children. In-depth interviews were conducted to probe participants on their views of these methods. Results: One Participatory Video was produced and four Digital Stories. Of the initial eight caregivers who took part in the Participatory Video process, four completed both the Digital Storytelling process and an in-depth interview about their experiences.  The main factors shaping participants’ experiences related to the skills learned in making the videos, the feeling of collectiveness and the control over the processes. Conclusion: Women with children with Congenital Zika Syndrome have reported feeling marginalised and misunderstood in daily life. This case study found that Participatory Visual Methods is acceptable and feasible. Moreover, these approaches can support groups in different aspects, such as providing a space to share their stories creatively, hear others in similar situations as them and increase the feeling of community.

Functioning profiles of individuals with Mucopolysaccharidosis according to the International Classification of Functioning

BACKGROUND

The classification of health problems of persons with Mucopolysaccharidosis (MPS) based on the International Classification of Functioning, Disability and Health (ICF) may contribute to better understanding the disease impacts. The ICF is a useful tool to describe disabilities and functioning, especially in diseases with multisystemic involvement.

AIM

To identify and classify the health needs of persons with non-neuronopathic MPS according to the ICF.

DESIGN

A cross-sectional study.

SETTING

Department of Physical Therapy (Federal University, Brazil).

POPULATION

Persons with non-neuronopathic MPS.

METHODS

Semi-structured interviews covering all components of the ICF were conducted to know the patients' perspectives of their health problems (patient-reported outcomes). The speeches were transcribed verbatim and analyzed by researchers to identifying meaningful concepts. Then, the concept units were linked to ICF components and the magnitude of the problem to ICF qualifiers. Data are shown by descriptive statistics and separated into two groups: children and adolescents, and adults.

RESULTS

A total of 60 different ICF categories were used to classify participants' functioning. A total of 28 and 51 categories was necessary to classify the health problems of children and adults, respectively. Additionally, 16 categories related to contextual factors were used, of which eight and 12 were identified as facilitators by children, adolescents, and adults, respectively. The main problems were related to supportive functioning of arms or legs (b7603), pain in the body part (b2801), respiratory functions (b440), and voice functions (b310). Limitations in the activity and participation component were related to walking (d450), fine hand use (d440), washing oneself (d510), and dressing (d540). Recreation and leisure (d920) was restricted to approximately half of the studied population.

CONCLUSIONS

People with MPS face impairments of body structures and functions, activity limitations and restrictions to participation. Environmental factors may be act as facilitators of these problems.

CLINICAL REHABILITATION IMPACT

The ICF is a useful tool to classify the health problems of people with non-neuropathic MPS. The planning of rehabilitation programs needs to covers all components of functioning to provide a biopsychosocial model of care. The ICF categories may direct health professionals to more effective targets.

Gross motor function in children with Congenital Zika Syndrome from Rio de Janeiro, Brazil

Congenital Zika Syndrome (CZS) is characterized by many impairments especially in the central nervous system, potentially compromising neurodevelopment and causing significant morbidity in affected children. The aim was to assess gross motor function in children with CZS. This was a cross-sectional investigation nested within a prospective cohort study of children with CZS based in a Brazilian referral hospital in Rio de Janeiro. Between March/2017 and February/2018, we performed gross motor function assessments using the Gross Motor Function Classification (GMFCS) and the Gross Motor Function Measure (GMFM), estimating the mean and standard deviation of GMFM scores among GMFCS groups. The study sample included 72 children, with a median age of 13 months (7-25). Of these, 63 (87.5%) had severe motor impairment, 3 (4%) had moderate impairment, and 6 (8%) had mild impairment. The mean GMFM score for each group was respectively 11.6, 26.1, and 81.6, with statistically significant differences (p-value < 0.001). Severely affected children only achieved head control in the sitting posture when supported. Children with milder forms were able to develop walking skills.Conclusion: Most children with CZS have major motor disabilities and a poor prognosis. Better understanding of limitations and functionality in children with CZS can serve as a prognostic guide in their management. What is Known: • Severe motor impairment was present in 63 (87.5%) children with CZS. • The degree of neurological impairment was inversely associated with motor performance. What is New: • Microcephaly was more frequent among children with severe gross motor function impairment. • Children with CZS have major motor disabilities and a poor prognosis.

Impact of congenital Zika virus and COVID-19 on childhood disability in Latin America

Spanish and Portuguese translations of this editorial are available in the online issue.

Pregnancy, Birth, Infant, and Early Childhood Neurodevelopmental Outcomes among a Cohort of Women with Symptoms of Zika Virus Disease during Pregnancy in Three Surveillance Sites, Project Vigilancia de Embarazadas con Zika (VEZ), Colombia, 2016-2018

Project Vigilancia de Embarazadas con Zika (VEZ), an intensified surveillance of pregnant women with symptoms of the Zika virus disease (ZVD) in Colombia, aimed to evaluate the relationship between symptoms of ZVD during pregnancy and adverse pregnancy, birth, and infant outcomes and early childhood neurodevelopmental outcomes. During May-November 2016, pregnant women in three Colombian cities who were reported with symptoms of ZVD to the national surveillance system, or with symptoms of ZVD visiting participating clinics, were enrolled in Project VEZ. Data from maternal and pediatric (up to two years of age) medical records were abstracted. Available maternal specimens were tested for the presence of the Zika virus ribonucleic acid and/or anti-Zika virus immunoglobulin antibodies. Of 1213 enrolled pregnant women with symptoms of ZVD, 1180 had a known pregnancy outcome. Results of the Zika virus laboratory testing were available for 569 (48.2%) pregnancies with a known pregnancy outcome though testing timing varied and was often distal to the timing of symptoms; 254 (21.5% of the whole cohort; 44.6% of those with testing results) were confirmed or presumptive positive for the Zika virus infection. Of pregnancies with a known outcome, 50 (4.2%) fetuses/infants had Zika-associated brain or eye defects, which included microcephaly at birth. Early childhood adverse neurodevelopmental outcomes were more common among those with Zika-associated birth defects than among those without and more common among those with laboratory evidence of a Zika virus infection compared with the full cohort. The proportion of fetuses/infants with any Zika-associated brain or eye defect was consistent with the proportion seen in other studies. Enhancements to Colombia's existing national surveillance enabled the assessment of adverse outcomes associated with ZVD in pregnancy.

Congenital Zika Virus Syndrome: care in light of the Brazilian Unified Health System principles

OBJECTIVE

to know health professionals' perceptions about care actions provided to children with Congenital Zika Virus Syndrome and their families.

METHODS

this is a qualitative study, carried out in a capital of center-western Brazil, based on the Unified Health System theoretical precepts. Data were collected in September and October 2020, through audio-recorded interviews with 12 health professionals from a specialized service and submitted to analysis of content, thematic modality.

RESULTS

the implementation of care actions with these children occurs through multidimensional assessment of children and their families, use of the Unique Therapeutic Project, therapeutic interventions for the development of children and the communication and exchange of interprofessional and family experiences, in addition to considering professionals' prior knowledge and their search for it.

FINAL CONSIDERATIONS

children with CZS and their families need individualized, frequent, integrated and continuous care.

Sleep in children with microcephaly due to Zika virus infection: a systematic review

OBJECTIVE

To review the literature on sleep changes and brain function in children with microcephaly due to Zika virus.

METHOD

Systematic review conducted in the databases MEDLINE (PubMed), Scopus, Web of Science, CINAHL, EMBASE, LILACS, and SciELO and the grey databases Google Scholar and OpenGrey.

RESULTS

Ten Brazilian primary studies with observational research design were included. These were published between 2017 and 2020 with 516 children with microcephaly due to Zika virus infection aged 4 months to 4 years. Out of these, 4 investigated qualitative aspects of sleep using the questionnaires Brief Infant Sleep Questionnaire or Infant Sleep Questionnaire and 6 investigated changes in brain activities during sleep using the Electroencephalogram or Video-Electroencephalogram exams. The children's quality of sleep was not compromised in most studies. Changes in brain activity during sleep were frequent, with epileptogenic activity being a common finding among the studies.

CONCLUSION

The quality of sleep of children with microcephaly due to Zika virus has shown to be similar to that of children with typical development and the presented behavioral changes may be related to changes in electric brain activity.

Congenital Zika Infection and the Risk of Neurodevelopmental, Neurological, and Urinary Track Disorders in Early Childhood. A Systematic Review

It was late 2015 when Northeast Brazil noticed a worrying increase in neonates born with microcephaly and other congenital malformations. These abnormalities, characterized by an abnormally small head and often neurological impairment and later termed Congenital Zika Syndrome, describe the severity of neurodevelopmental and nephrological outcomes in early childhood, and the implication of microcephaly at birth. The purpose of the study was to describe the neurodevelopmental outcomes in children exposed to Zika virus during fetal life, with and without microcephaly at birth. The systematic review included research studies about the neurodevelopmental outcomes with and without microcephaly, as well as nephrological outcomes in early childhood. We searched PubMed, Crossref, PsycINFO, Scopus, and Google Scholar publications and selected 19 research articles published from 2018 to 2021. Most studies have linked the severity of microcephaly in childbirth to the neurodevelopmental and urinary outcomes in early childhood. However, most children without microcephaly at birth develop typically, while others may be at risk for language impairment.

Early Gross Motor Development Among Brazilian Children with Microcephaly Born Right After Zika Virus Infection Outbreak

OBJECTIVE

To assess the gross motor development of children with presumed congenital Zika virus (ZIKV) infection over the first 2 years of their lives.

METHODS

Seventy-seven children were assessed at the median ages of 11, 18, and 24 months, using the evaluative instrument Gross Motor Function Measure (GMFM-66). At the third assessment, the children with diagnoses of cerebral palsy (CP) were classified by severity through the Gross Motor Function Classification System (GMFCS) and stratified by topography indicating the predominantly affected limbs. With these instruments in combination and using the motor development curves as reference, the rate of development and functional ability were estimated.

RESULTS

At 2 years of age, all children had the diagnosis of CP. Seventy-four (96.1%) presented gross motor skills similar to those of children aged 4 months or younger, according to the World Health Organization's standard. The GMFM-66 median score among the 73 (94.8%) children with quadriplegia and GMFCS level V showed significant change between 11 and 18 months (p < 0.001) and between 11 and 24 months (p < 0.001). No significant difference (p = 0.076) was found between 18 and 24 months.

CONCLUSION

Despite showing some gross motor progress during the initial 18 months of life, these children with presumed congenital ZIKV infection and CP experienced severe motor impairment by 2 years of age. According to the motor development curves, these children with quadriplegia have probably already reached about 90% of their motor development potential.

Developing a Culturally Sensitive ICF-Based Tool to Describe Functioning of Children with Autism Spectrum Disorder: TEA-CIFunciona Version 1.0 Pilot Study

BACKGROUND

Autism spectrum disorder (ASD) affects the daily functioning of children and their families; however, in Argentina, there are no standardized tools to guide the description, evaluation, and follow-up of functioning and disability of children with ASD. To fill this gap, the overarching purpose of this study was to create a novel tool guided by the International Classification of Functioning, Disability, and Health (ICF) Core Sets for ASD for clinical practice.

METHODS

A multistep methodology was used to identify the most relevant ICF categories for an Argentinian clinical setting. The content of this ICF-based shortlist was piloted and revised according to the results. Subsequently, a toolbox of measures was proposed to operationalize each ICF category. Finally, profiles of the functioning of 100 children with ASD were created.

RESULTS

An ICF-based tool called TEA-CIFunciona was created, consisting of 32 ICF categories (10 body functions, 15 activities and participation, 7 environmental factors categories). The application of TEA-CIFunciona incorporated a family-centered approach in ASD evaluations and helped identify functional needs.

CONCLUSIONS

TEA-CIFunciona is the first ICF-based instrument that guides the description of functioning of children with ASD in Argentina. TEA-CIFunciona standardizes collaborative assessments in pediatric ASD populations in Latin American contexts.

Promoting Developmental Potential in Early Childhood: A Global Framework for Health and Education

In the early years of life, children’s interactions with the physical and social environment- including families, schools and communities—play a defining role in developmental trajectories with long-term implications for their health, well-being and earning potential as they become adults. Importantly, failing to reach their developmental potential contributes to global cycles of poverty, inequality, and social exclusion. Guided by a rights-based approach, this narrative review synthesizes selected studies and global initiatives promoting early child development and proposes a universal intervention framework of child-environment interactions to optimize children’s developmental functioning and trajectories.

Gross Motor Function in Children with Congenital Zika Syndrome

BACKGROUND

Little information on gross motor function of congenital Zika syndrome (CZS) children is available.

OBJECTIVES

To evaluate gross motor function in CZS children aged up to 3 years, and its associated factors and changes in a minimum interval of 6 months.

METHODS

One hundred children with CZS and cerebral palsy (36 with confirmed and 64 with presumed CZS) were evaluated with the Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM-88/GMFM-66). Forty-six were reevaluated. Wilcoxon tests, Wilcoxon tests for paired samples, percentile scores, and score changes were performed.

RESULTS

Clinical and socioeconomic characteristics (except maternal age), GMFM scores and GMFCS classification of confirmed and probable cases, which were analyzed together, were similar. The mean age was 25.6 months (±5.5); the median GMFM-88 score was 8.0 (5.4-10.8); and the median GMFM-66 score was 20.5 (14.8-23.1); 89% were classified as GMFCS level V. Low economic class, microcephaly at birth, epilepsy, and brain parenchymal volume loss were associated with low GMFM-66 scores. The median GMFM-66 percentile score was 40 (20-55). On the second assessment, the GMFM-66 scores in two GMFCS level I children and one GMFCS level IV child improved significantly. In one GMFCS level III child, one GMFCS level IV child, and the group of GMFCS level V children, no significant changes were observed.

CONCLUSIONS

Almost all CZS children had severe cerebral palsy; in the third year of life, most presented no improvement in gross motor function and were likely approaching their maximal gross motor function potential.

Time to Evaluate the Clinical Repercussions of Zika Virus Vertical Transmission? A Systematic Review

Background: Vertical transmission of Zika Virus (ZIKV) can be associated with several clinical features in newborn infants. The goal of the present review was to analyze the current state of knowledge regarding clinical repercussions following perinatal exposure to ZIKV in children up to 3 years of age. Methods: A systematic review of published studies was carried out, without the restriction of language or date of publication, identified in the databases PubMed, Virtual Health Library (BVS), Scopus, and Web of Science and the catalog for CAPES theses and dissertations. According to the proposed flowchart, the bibliographic search resulted in 1,563 papers. Of these, according to the eligibility criteria, 70 were selected for systematic review; all were published between 2016 and 2021. Results: Regarding clinical findings, 19 papers evaluated clinical imaging alterations, 21 ophthalmic manifestations, and 39 evaluated the central nervous system; of these, 15 analyzed neuro-psychomotor development. The remainder evaluated audiological (n = 14), nutritional (n = 14), orthopedic (n = 7), cardiorespiratory (n = 5), genitourinary (n = 3) or endocrinological (n = 1) manifestations. Conclusion: It is critical for studies to continue monitoring children with antenatal ZIKV exposure as they grow, given the unknown long-term repercussions of ZIKV and the recognized postnatal complications of this infection during pregnancy. Broader descriptions of observed clinical findings are also important in order to characterize the entire spectrum of disease in children. Systematic Review Registration: PROSPERO REGISTER: CRD42020205947.

The neurodevelopmental spectrum of congenital Zika infection: a scoping review

AIM

To describe the standardized neurodevelopmental outcomes after the first year of life in children with congenital Zika syndrome (CZS) and those exposed to Zika virus (ZIKV) during fetal life, but without microcephaly at birth.

METHOD

This scoping review included observational studies about the standardized neurodevelopmental outcome in children with CZS or exposed to ZIKV, but without microcephaly, assessed after 12 months of age. The databases searched were MEDLINE/Pubmed, LILACS, Scielo, Scopus, PsycINFO, CINAHL, and Embase. Risk of bias was assessed with the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Seventeen papers were included: 12 focused on children with CZS, four on children born without microcephaly, and one described both. Only one of the studies about CZS reported a child with microcephaly and typical development; the remainder described a severe pattern of global developmental delay and cerebral palsy. The prevalence of epilepsy was 74.6%. In the reports about children born without microcephaly, 6.9% to 8.7% had some domain with a score below -2 SD, and three children developed autism spectrum disorder.

INTERPRETATION

CZS is associated with severe global developmental delay and cerebral palsy after 1 year of age. In children born without microcephaly, although most have typical development, some may be at risk for impairments.

Go Zika Go: A Feasibility Protocol of a Modified Ride-on Car Intervention for Children with Congenital Zika Syndrome in Brazil

Children with congenital Zika syndrome (CZS) present severe motor disability and can benefit from early powered mobility. The Go Zika Go project uses modified ride-on toy cars, which may advance the body functions, activities, and participation of children. This paper describes the study protocol aiming to assess the feasibility of a modified ride-on car intervention for children with CZS in Brazil. A mixed-methods design with a multiple 1-week baseline, 3-month intervention, and 1-month follow-up will be implemented. Modified ride-on car training sessions will be conducted three times a week at the participants’ home or in the clinic. The primary outcome will be a narrative description of study feasibility (photovoice method, focus groups, parent feasibility questionnaire and assessment of learning powered mobility). Secondary outcomes will be switch activation, driving sessions journal, social-cognitive interactions, mobility (pediatric evaluation of disability inventory computer adaptive test), goal attainment scaling (GAS), and participation (young children’s participation and environment measure). Go Zika Go is expected to be viable and to improve function, activity, and participation of children with CZS, providing a low-cost, evidence-based rehabilitation option that will be relevant to early child development in a global perspective.

Motor development in non-microcephalic infants born to mothers with Zika Virus infection during pregnancy

ABSTRACT This cross-sectional study sought to evaluate motor development in infants exposed to ZIKV born with normal head circumference (HC). Thirty one children, distributed into two groups, participated in the study: 15 whose mothers were infected by ZIKV during pregnancy, born with HC from −1.9 to +2 Z-scores, adjusted for sex and gestational age (exposed group); and 16 randomly selected infants without known prenatal exposure to ZIKV, paired by sex and age (control group). Alberta Infant Motor Scale (AIMS) was used to evaluate gross motor development. We found no significant difference between the exposed and control groups. However, considering that AIMS is a screening test that assesses only the gross motor development and the small size of our sample, infants exposed to ZIKV during pregnancy should be continuously evaluated for different aspects of their development.

Breastfeeding Behavior in Brazilian Children with Congenital Zika Syndrome

Congenital Zika Syndrome (CZS) is a condition that has emerged only recently, bringing together multiple changes, including significant changes in the stomatognathic system, which may compromise sucking behavior and consequently the breastfeeding practice. The aim of this study was to investigate the breastfeeding behaviors in children with CZS. A longitudinal study was carried out in two reference centers in Northeastern Brazil. The nonprobabilistic sample consisted of 79 children diagnosed with physical, neurological, and behavioral alterations compatible with CZS. Information regarding the child, nutritive, and nonnutritive sucking behavior and changes related to the sucking reflex was collected. Data were presented through descriptive and inferential statistics. In the bivariate analyses, the chi-squared test was used and 5% significance level was adopted. The majority of children had severe microcephaly (59.7%). Breastfeeding was performed at birth in most of CZS children (89.9%) but only 36.6% of them presented exclusive breastfeeding in the six months of life. Bottle feeding and pacifier were used in 89.9% and 55.7%, respectively. Sucking and swallowing difficulties and occurrence of gastroesophageal reflux were observed in 27.8%, 48.0%, and 29.2% of children, respectively. Early weaning was associated with bottle feeding (p=0.005) and pacifier sucking (p=0.003). Although breastfeeding practice at birth constitutes a behavior adopted by most of mothers, adherence to this exclusive habit until the first six months of life was low since the children presenting a large number of comorbidities with direct interference in the suction reflex, sucking, and swallowing difficulty.

Neurodevelopment of Nonmicrocephalic Children, After 18 Months of Life, Exposed Prenatally to Zika Virus

The aim of this work was to evaluate the cognitive, language, and motor development, after 18 months of life, of nonmicrocephalic children born to mothers with Zika virus infection during pregnancy. Participants were 37 children aged 18-29 months divided into 2 groups: 17 nonmicrocephalic children born to mothers who had Zika virus infection during pregnancy (ZIKVG) and 20 nonmicrocephalic children with no maternal history of infection matched by sex and age (control group). A semistructured interview and the Bayley Scale of Infant and Toddler Development (Bayley III) were used for their evaluation. One child in the ZIKVG presented low cognitive score, the same in the control group. There were no statistical differences between the 2 groups regarding cognitive, language, and motor development. This sample, although small, showed that a significant proportion of nonmicrocephalic children exposed prenatally to Zika virus had normal development. A longer follow-up is necessary to observe if no other adverse outcomes will appear in the future.

Cerebral Palsy in Children With Congenital Zika Syndrome: A 2-Year Neurodevelopmental Follow-up

OBJECTIVE

To describe the 2-year neurodevelopmental outcome in children with cerebral palsy associated with congenital Zika (CZ) and explore variables associated with a more severe presentation.

METHODS

Data on 69 children with cerebral palsy associated with CZ, followed in a neurorehabilitation hospital, who consecutively attended the neurodevelopmental assessment at 2 years of age, were collected. Bayley III Scales of Infant and Toddler Development, Hammersmith Infant Neurological Examination, and Gross Motor Function Classification System were used for the outcome evaluation. Descriptive and inferential statistical analysis were performed.

RESULTS

The median age at follow-up was of 24.0 (23-32) months. Only 3 (4.3%) children were not microcephalic. The majority presented with bilateral (94.2%), spastic (100.0%), Gross Motor Function Classification System grade IV or V (92.8%) cerebral palsy, epilepsy (73.1%), extremely low performances on cognitive (94.2%), language (95.7%), and motor (95.7%) Bayley-III Scales of Infant and Toddler Development Test scores. The median Hammersmith Infant Neurological Examination score was of 21.0 (range 9-75). There was a correlation between birth head circumference with the cognitive (r = 0.3, P < .01), language (r = 0.3, P < .01), and motor (r = 0.3, P < .01) Bayley-III Scales of Infant and Toddler Development Test scores, as well as with the Hammersmith Infant Neurological Examination score (r = 0.2, P < .03). An association was observed between an inferior median Hammersmith Infant Neurological Examination score with congenital microcephaly (P = .04), arthrogryposis (P = .02), and epilepsy in the first year (P < .01).

CONCLUSION

Cerebral palsy related to CZ presents with a severe global impairment at a 2-year follow-up. Birth head circumference, arthrogryposis, and early epilepsy are associated with a worse outcome and may be considered as prognostic markers. These findings are important for the neurorehabilitation planning, parents' guiding, and future prognostic studies.

Anxiety and depression among caregivers of young children with Congenital Zika Syndrome in Brazil

PURPOSE

To examine the psychological well-being of primary caregivers of infants and toddlers with Congenital Zika Syndrome (CZS), and the roles of family resources, parenting stress, and coping strategies in caregivers' adaptation.

MATERIALS AND METHODS

Family caregivers (N = 50) of children with CZS who were receiving treatment at a rehabilitation hospital in Recife, Brazil participated a cross-sectional survey study. Caregivers completed measures of anxiety and depression, coping strategies, family resources, and parenting stress.

RESULTS

Mild to severe symptoms of depression were identified in 40% of caregivers and were a more prominent concern than symptoms of anxiety. Fewer family resources and high levels of parenting stress were significantly associated with both anxiety and depression. The association between parenting stress and depression was moderated by coping, such that parenting stress was associated with higher caregiver depression at low but not high levels of coping strategy use.

CONCLUSIONS

Practitioners in Brazil should consider the role of family coping and resources as important resilience promoting factors in the development of new programs designed to promote psychological adaptation in caregivers to children with CZS. It is recommended that caregiver mental health support services be integrated into existing early intervention programs targeting children with CZS.Implications for RehabilitationParents and other primary caregivers are encouraged to take an active role in the care and developmental monitoring of children born with CZS, but their ability to provide care may be compromised by difficulties in psychological adaptation.Moderate and severe symptoms of depression were more prominent in caregivers than moderate and severe symptoms of anxiety (20% versus 6%, respectively).Practitioners should include assessment of coping strategies, parenting stress and family resources conjointly with evaluation of symptoms of depression and anxiety as part of routine CZS family evaluations.A useful approach for caregivers in Brazil may be to more fully integrate caregiver mental health support services into existing early intervention programs for children with CZS.

Zika Virus After Emergency Response: Can the ICF Guide Rehabilitation of Children With Microcephaly?

The outbreak of Zika in Brazil almost 3 years ago had harmful medical, financial, and social consequences for children and their families. It also significantly increased the statistics of Brazilian children with disabilities being followed up in rehabilitation centers. Actions promoting the use of the International Classification of Functioning, Disability and Health (ICF) framework are encouraged in view of the complex health needs identified in this population, which cover all areas of functioning, and gain special relevance when it comes to a vulnerable context. This perspective article discusses the challenges related to the implementation of the ICF in rehabilitation services for children with congenital syndrome.

Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: A living systematic review

Background: The Zika virus (ZIKV) caused a large outbreak in the Americas leading to the declaration of a Public Health Emergency of International Concern in February 2016. A causal relation between infection and adverse congenital outcomes such as microcephaly was declared by the World Health Organization (WHO) informed by a systematic review structured according to a framework of ten dimensions of causality, based on the work of Bradford Hill. Subsequently, the evidence has continued to accumulate, which we incorporate in regular updates of the original work, rendering it a living systematic review.

Methods: We present an update of our living systematic review on the causal relation between ZIKV infection and adverse congenital outcomes and between ZIKV and GBS for four dimensions of causality: strength of association, dose-response, specificity, and consistency. We assess the evidence published between January 18, 2017 and July 1, 2019.

Results: We found that the strength of association between ZIKV infection and adverse outcomes from case-control studies differs according to whether exposure to ZIKV is assessed in the mother (OR 3.8, 95% CI: 1.7-8.7, I ²=19.8%) or the foetus/infant (OR 37.4, 95% CI: 11.0-127.1, I ²=0%). In cohort studies, the risk of congenital abnormalities was 3.5 times higher after ZIKV infection (95% CI: 0.9-13.5, I ²=0%). The strength of association between ZIKV infection and GBS was higher in studies that enrolled controls from hospital (OR: 55.8, 95% CI: 17.2-181.7, I ²=0%) than in studies that enrolled controls at random from the same community or household (OR: 2.0, 95% CI: 0.8-5.4, I ²=74.6%). In case-control studies, selection of controls from hospitals could have biased results.

Conclusions: The conclusions that ZIKV infection causes adverse congenital outcomes and GBS are reinforced with the evidence published between January 18, 2017 and July 1, 2019.

Using Risk Communication Strategies for Zika Virus Prevention and Control Driven by Community-Based Participatory Research

Background: In this study, we use community-based participatory processes to engage community and academic partners in a meaningful exchange to identify and pilot test risk communication strategies for Zika virus prevention and control. Methods: Community members were actively involved in planning, developing, and implementing a risk communication initiative. Qualitative and quantitative data gathered through individual interviews, focus groups, and community advisory board input provided information for the identification of relevant risk communication strategies to increase the understanding about Zika virus and to promote behavior change. To examine its impact we obtained baseline and follow-up data from a random sample of 75 community residents. A face-to-face interview was conducted to assess community members' knowledge, attitudes, and behaviors regarding Zika virus infection. Results: Study activities focused on three risk communication strategies: Zika awareness health fair, health education through theater, and community forums and workshops. The risk communication initiative was implemented over a two-month period. Findings from baseline and follow-up data demonstrated significant positive changes in respondents' recognition of personal and community responsibility for the prevention of Zika infection, increased knowledge of prevention strategies, and enhanced engagement in preventive behaviors for mosquito control. Conclusion: Our findings sustain the benefits of community based participatory research for the design and implementation of risk communication strategies that are relevant to enable residents in low-income communities to take informed decisions for the protection against Zika virus and other mosquito-borne diseases.

Growth and Development of Children with Microcephaly Associated with Congenital Zika Virus Syndrome in Brazil

The outbreak of Zika virus in Latin America in the period 2015–2016 has caused a sudden increase in the number of severe manifestations and reports of congenital changes in newborns in Brazil. This is the first study that evaluated and compared the growth and cognitive and motor development of children with microcephaly due to Congenital Zika Virus Syndrome (CZS) in relation to typical children. It was an observational, analytical, cross-sectional study with 8 children with CZS and 16 typical children, with a mean age of 20.5 months (±2.1), in a region of northeastern Brazil. Considering the mean, children with CZS presented extremely low performance in the motor domain and in the cognitive development domain, whereas typical children presented average performance in the cognitive and motor development domains. Children with CZS presented a mean growth rate (head circumference and weight) lower than typical children. Therefore, children with CZS are at risk for growth retardation and development compared to typical children.

Implementation of the International Classification of Functioning, Disability, and Health (ICF) Core Sets for Children and Youth with Cerebral Palsy: Global Initiatives Promoting Optimal Functioning

Background: The International Classification of Functioning, Disability, and Health (ICF) Core Sets for children and youth with cerebral palsy (CP) offer service providers and stakeholders a specific framework to explore functioning and disability for assessment, treatment, evaluation, and policy purposes in a global context. Objective: Describe global initiatives applying the ICF Core Sets for children and youth with CP, with a focus on contributions to clinical practice and challenges in their implementation. Methods: This is a descriptive cross-sectional study. Ongoing initiatives applying the ICF Core Sets for CP in Russia, Poland, Malawi, and Brazil are included. Results: The main contributions of applying the ICF Core Sets for children and youth with CP include: (1) an objective description of abilities and limitations in everyday activities; (2) a consistent identification of facilitators and barriers influencing functioning; (3) a practical communication tool promoting client-centered care and multidisciplinary teamwork; and, (4) a useful guideline for measurement selection. The main challenges of adopting the ICF Core Sets are related to lack of ICF knowledge requiring intense training and translating results from standardized measures into the ICF qualifiers in a consistent way. Conclusions: Global initiatives include research and clinical applications at the program, service and system levels. The ICF Core Sets for CP are useful tools to guide service provision and build profiles of functioning and disability. Global interprofessional collaboration, capacity training, and informatics (e-records) will maximize their applications and accelerate adoption.