What is the management of a 1-day-old neonate born to a mother who developed varicella (chickenpox) 3 days prior to delivery?

From the Guidelines

The management of a 1-day-old baby whose mother developed chickenpox 3 days before delivery requires immediate administration of varicella-zoster immune globulin (VZIG) at a dose of 125 units/10 kg intramuscularly as a single dose, ideally within 96 hours of birth.

Key Considerations

• The infant should receive intravenous acyclovir at 10-15 mg/kg every 8 hours for 7-10 days to reduce the severity of varicella infection, as supported by the guidelines for prevention of varicella 1.
• The baby should be isolated from other infants and closely monitored for signs of infection such as fever, lethargy, or vesicular rash for at least 21 days, due to the high risk of severe varicella infection in this population.
• Breastfeeding can continue if the mother's lesions are not present on the breast and are covered elsewhere, as the benefits of breastfeeding outweigh the risks of varicella transmission in this context.

Rationale

The risk of severe varicella infection in neonates born to mothers who develop chickenpox within 5 days before to 2 days after delivery is estimated to be 17-30% 1.

• The use of VZIG has been shown to reduce the incidence of severe neonatal varicella disease 1.
• The administration of acyclovir can help inhibit viral replication and reduce the severity of varicella infection.
• Close monitoring of the infant is crucial, as breakthrough infection can still occur despite treatment.

Important Notes

• The guidelines for prevention of varicella recommend the use of VZIG for neonates whose mothers have signs and symptoms of varicella from 5 days before to 2 days after delivery 1.
• The risk of neonatal death due to varicella infection is estimated to be 31% among infants whose mothers had onset of rash <4 days before giving birth 1.

From the FDA Drug Label

VARIZIG® [Varicella Zoster Immune Globulin (Human)] is indicated for post-exposure prophylaxis of varicella in high risk individuals High risk groups include: immunocompromised children and adults, newborns of mothers with varicella shortly before or after delivery, premature infants, neonates and infants less than one year of age, adults without evidence of immunity, pregnant women. Administer VARIZIG as soon as possible following varicella zoster virus (VZV) exposure, ideally within 96 hours for greatest effectiveness.

The management for a 1-day-old baby of a mother who develops chicken pox 3 days before delivery is post-exposure prophylaxis with Varicella Zoster Immune Globulin (VARIZIG), which should be administered as soon as possible, ideally within 96 hours of exposure. The dose of VARIZIG is based on body weight, with a minimum dose of 62.5 international units for small infants under 2 kilograms body weight.

• Key considerations:
  • Timing of administration: As soon as possible, ideally within 96 hours of exposure.
  • Dosing: Based on body weight, with a minimum dose of 62.5 international units for small infants under 2 kilograms body weight.
  • Administration: Intramuscularly, divided into two or more injection sites if necessary, depending on patient size 2.

From the Research

Management of Varicella-Zoster Virus Infection

The management of varicella-zoster virus infection in a 1-day-old baby whose mother developed chickenpox 3 days before delivery is crucial to prevent severe complications.

• The baby is at high risk of developing severe varicella due to the mother's infection close to the time of delivery 3.
• Antiviral therapy, such as acyclovir, is the primary treatment for varicella-zoster virus infections, especially in high-risk populations like immunocompromised individuals or newborns 4, 5.
• The American Academy of Pediatrics recommends the use of varicella-zoster immune globulin (VariZIG) for postexposure prophylaxis in high-risk individuals, including newborns whose mothers develop varicella around the time of delivery.
• The sequential use of intravenous and oral acyclovir has been shown to be effective in treating varicella in immunocompromised children, reducing the duration of intravenous therapy and hospitalization 5.
• Newer antiviral agents, such as valacyclovir, famciclovir, and amenamevir, have also been approved for the treatment of varicella-zoster virus infections, offering alternative treatment options 6, 7.

Treatment Options

• Acyclovir is the most commonly used antiviral medication for treating varicella-zoster virus infections, and it can be administered intravenously or orally, depending on the severity of the infection and the patient's immunocompetence 4.
• The dosage and duration of antiviral therapy may vary depending on the patient's age, weight, and immune status, as well as the severity of the infection.
• In addition to antiviral therapy, supportive care, such as hydration, pain management, and monitoring for complications, is essential in managing varicella-zoster virus infections.

Prevention

• Varicella-zoster virus infections can be prevented through vaccination, which is recommended for all children and adults who have not had varicella or have not been vaccinated 6, 3.
• Postexposure prophylaxis with varicella-zoster immune globulin (VariZIG) can also be effective in preventing varicella in high-risk individuals, including newborns whose mothers develop varicella around the time of delivery.