Rotavirus infection and bradycardia-apnoea-episodes in the neonate

White matter injury following rotavirus infection in neonates: new aspects to a forgotten entity, 'fifth day fits'?

That rotavirus infection can cause neurological symptoms in young children has been well established. However, it is surprising why rotavirus infection has been overlooked as a cause of neonatal seizures for many years, despite significant research interest in neonatal rotavirus infection. Neonates are the age group most vulnerable to seizures, which are typically attributed to a wide range of causes. By contrast, because rotavirus infection is usually asymptomatic, it has been difficult to identify an association between this virus and neonatal seizures. The conventional wisdom has been that, although neonates are commonly infected with rotavirus, neurological complications are rare in this age. However, recent studies using diffusion-weighted imaging (DWI) have suggested a connection between rotavirus infection and neonatal seizures and that rotavirus infection can induce diffuse white matter injury without direct invasion of the central nervous system. The clinical features of white matter injury in rotavirus-infected neonates include the onset of seizures at days 4–6 of life in apparently healthy term infants. The recent findings seem to contradict the conventional wisdom. However, white matter injury might not be a completely new aspect of rotavirus infection in neonates, considering the forgotten clinical entity of neonatal seizures, 'fifth day fits'. With increased use of DWI in neonatal seizures, we are just starting to understand connection between viral infection and white matter injury in neonates. In this review, we discuss the historical aspects of rotavirus infection and neonatal seizures. We also present the clinical features of white matter injury in neonatal rotavirus infection.

Pseudo-outbreak of rotavirus infection in a neonatal intensive care unit

BACKGROUND

A rotavirus outbreak in a neonatal intensive care unit (NICU) may have catastrophic consequences for young infants receiving critical care. From May 13, 2011 to July 11, 2011, a significant increase in stool samples testing positive for rotavirus antigens in the NICU of a university affiliated hospital was observed. Due to lack of clinical presentations suggestive of rotavirus infection in the patients and the rarity of rotavirus infection in the NICU in the past, a pseudo-outbreak was suspected.

METHODS

Infection control measures were reinforced initially. To investigate the outbreak, a prospective laboratory-based active surveillance of all infants in the NICU was conducted right after the cluster was identified. Repeated testing using a modified enzyme immunoassay (EIA) kit, rotavirus RNA polyacrylamide gel electrophoresis (PAGE), reverse transcription polymerase chain reaction (RT-PCR), and retrospective chart review methods were used to confirm the pseudo-outbreak.

RESULTS

Seven infants in the NICU, with or without gastrointestinal symptoms, tested positive for the rotavirus antigen using the old version of an EIA kit, which indicated a possible outbreak. Active surveillance with repeated tests for recollected stool samples using a modified EIA kit showed negative results in all 24 infants in the NICU. Seven stored stool samples from four infants, which previously tested positive for the rotavirus antigen, tested negative for rotavirus using the modified EIA kit, PAGE, and RT-PCR. Chart reviews showed no clinical difference between index cases and controls. False positivity might arise from unsatisfactory specificity of the old EIA kit. After the introduction of the modified EIA kit, no rotavirus was detected in the NICU for at least 7 months.

CONCLUSION

This cluster of patients who tested positive for the rotavirus antigen in stools was confirmed to be a pseudo-outbreak. Interpretation of the old EIA for rotavirus in an NICU setting should be done with caution until the mechanism of the false-positive reaction is elucidated.

Neonatal seizures accompanied by diffuse cerebral white matter lesions on diffusion-weighted imaging are associated with rotavirus infection

BACKGROUND AND AIMS

Some full-term neonates presenting seizures show diffusion-restricted lesions in the cerebral white matter on brain diffusion-weighted imaging (DWI). The purpose of this study was to describe the clinical characteristics and DWI findings in a group of neonates with seizures, white matter lesions on DWI, and a high incidence of rotavirus infection.

METHODS

Total 30 full-term neonates with seizures were admitted between 2008 and 2010. Of these, 13 (group A) had the following characteristics on brain DWI: (1) diffusion-restricted lesions in the diffuse symmetric cerebral white matter, including the corpus callosum, and (2) no cerebral cortical lesions. The remaining 17 patients (group B) did not exhibit the DWI findings. The clinical characteristics were compared between the 2 groups.

RESULTS

The 1-min and 5-min Apgar scores ranged between 7 and 10 in all group A patients, whereas the scores were more diverse in the group B patients. Patients' age at seizure onset was 4.6 ± 0.6 days (range, 4-6 days) in group A and 8.3 ± 7.4 days (range, 1-27 days) in group B. Twelve of 13 patients (92.3%) in group A tested positive for stool rotavirus antigen, while only 2 of 12 (16.7%) in group B tested positive (p < 0.001). Six of 10 group A patients showed normal neurodevelopment, but 4 had delayed development between 6 and 30 months.

CONCLUSIONS

Rotavirus infection should be considered in neonates with seizures accompanied by diffuse cerebral white matter lesions on DWI, particularly around 5 days of life.

Complications in hospitalized children with acute gastroenteritis caused by rotavirus: a retrospective analysis

Acute gastroenteritis (AGE) caused by rotavirus (RV) is a common disease among infants and toddlers, often leading to hospitalization and, in resource-poor countries, to death. However, little is known on specific complications of severe RV-positive (RV+) AGE and on the clinical course in chronically ill children. This was a retrospective analysis of data for children <5 years of age hospitalized due to AGE during six rotavirus seasons in three large German pediatric hospitals. The primary study end point was the incidence and type of complications in RV+ versus RV-negative (RV-) cases. A total of 6,884 episodes of AGE in hospitalized children aged <5 years were included in this analysis. Of the 4,880 stools tested for RV, 2,118 (43.4%) were RV+. Hypernatremia was significantly more common in RV+ AGE (P < 0.001) and was associated with severe disease, need for intensive care treatment, and longer duration of hospitalization. Metabolic disorders, particularly hypoglycemia, were more common in RV+ AGE. In contrast, symptoms such as respiratory infections, neurological, and abdominal symptoms were more common in children with RV- AGE.

CONCLUSIONS

Hypernatremia is a specific complication of RV+ AGE. RV would therefore appear to be the cause of infant toxicosis, the traditional descriptive term for severe dehydration and clinical deterioration following AGE.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus is a common neonatal nosocomial viral infection and epidemics with the newer P(6)G9 strains have been reported. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalized low birthweight infants (birthweight < 2500 g)

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, CINAHL, biological Abstracts (BIOSIS), Science Citation Index for articles citing Barnes 1982 and the proceedings of the Pediatric Academic Societies from 1991 onwards were searched in July 2011. Ongoing trials were also searched at clinicaltrials.gov and controlled-trials.com

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) design: randomized or quasi-randomized controlled trials; 2) participants: hospitalized low birthweight infants; 3) intervention: oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention; 4) at least one of the following outcomes were reported: all cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection , duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea.

DATA COLLECTION AND ANALYSIS

The two review authors independently abstracted data from the included trials.

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalized low birthweight babies [RR 1.27 (95% CI 0.65 to 2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1 to 4 days) and the group who had placebo (mean 3 days, range 1 to 6 days). Barnes 1982 reported no adverse effects after administration of oral immunoglobulin preparations.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of oral immunoglobulin preparations to prevent rotavirus infection in low birthweight infants. Researchers are encouraged to conduct well-designed neonatal trials using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins) and include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus diarrhea in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. It is a major health problem worldwide. Epidemics with the newer P(6)G9 strains have been reported in neonatal units globally. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilization of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants (birth weight less than 2500 g)

SEARCH STRATEGY

Electronic databases including The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE, EMBASE and CINAHL, Biological Abstracts (BIOSIS) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles that referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies published online at 'Abstracts Online' were searched. Ongoing registered trials at www.clinicaltrials.gov and www.controlled-trials.com were searched. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed. The above search was updated in July 2011.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomized or quasi-randomized controlled trials 2) Hospitalized low birth weight infants with rotavirus diarrhea 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo or no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data were available for analysis.

MAIN RESULTS

No eligible randomized controlled trials were found.

AUTHORS' CONCLUSIONS

No randomized controlled trials that assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants were found. Clinical trials that address the issue of oral immunoglobulin treatment of rotavirus infection are needed.

[Rotavirus: an ubiquitous infection?]

Rotavirus is the most frequent virus found in childhood gastroenteritis. A rotavirus viremia is observed in 19 to 63 % of cases, for three days at the beginning of infection. Then, rotavirus can reach several organs as liver (hepatitis in 1/3 of case), nervous central system (2 % of encephalitis could be linked to rotavirus), or more infrequently mesenteric lymph nodes, lung or heart. However, the link between rotavirus and systemic manifestations has not been well established. Further studies are necessary to confirm the role of rotavirus in these organ's lesions.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2002), MEDLINE, EMBASE and CINAHL were searched. Science Citation Index was searched for all articles which referenced Barnes 1982. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research from 1991 onwards were searched as well as abstracts of doctoral dissertations and theses from 1960 onwards. The above mentioned search strategy was completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials. 2) PARTICIPANTS: Hospitalised low birthweight infants. 3) INTERVENTION: Oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention. 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea.

DATA COLLECTION AND ANALYSIS

The two reviewers independently abstracted data from the included trials

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Two additional studies are awaiting assessment re eligibility for inclusion. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalised low birthweight babies [RR 1.27 (95% CI 0.65-2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1-4 days) and the group who had placebo (mean 3 days, range 1-6 days). No adverse effects were reported by Barnes 1982 after administration of oral immunoglobulin preparations.

REVIEWER'S CONCLUSIONS

Current evidence from one randomised controlled trial does not support the routine use of oral immunoglobulin preparations for the prevention of rotavirus infection in low birth-weight infants. However, newer immunoglobulin preparations which have been found to be effective in older children have not been tested in neonatal trials. Therefore, researchers should be encouraged to conduct well designed trials in neonates at risk for rotavirus infections using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins). Such trials should also include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

Electronic databases including The Cochrane Controlled Trials Register (The Cochrane Llibrary, Issue 2, 2002), MEDLINE (1966 - June 2002), EMBASE (1980 - June 2002) and CINAHL (1982 - June 2002) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles which referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research, from 1991 were searched as well as abstracts of the doctoral dissertations and theses from 1960. All of the above search strategies were completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials 2) Hospitalised low birthweight infants with rotavirus infection 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo OR no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data analysis was possible at this point.

MAIN RESULTS

No eligible randomised controlled trials were found.

REVIEWER'S CONCLUSIONS

We found no randomised controlled trials which assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus infections in hospitalised low birthweight infants.

Hospital-acquired viral pathogens in the neonatal intensive care unit

Hospital-acquired infections caused by viruses are a cause of considerable morbidity and occasional mortality in critically ill neonates. The intensive care environment allows for efficient spread of viral pathogens, and secondary cases among both patients and healthcare workers are frequently observed. We review the common viral causes of hospital-acquired infections in neonates, including rotavirus, respiratory syncytial virus, and others, discuss epidemiology and clinical syndromes, and summarize recommendations for control in outbreak situations. Chemoprophylaxis, isolation procedures, and care of affected staff are also addressed.

Fatal, rotavirus-associated myocarditis and pneumonitis in a 2-year-old boy

Rotavirus infection is common in childhood. We report a 2-year-old boy admitted to hospital with gastro-enteritis who suffered cardio-respiratory arrest and died. Autopsy showed evidence of rotavirus-associated myocarditis and pneumonitis. We are not aware of any previous report of death from this type of consequence of rotavirus infection.

The current status of the rotavirus vaccine

The US just licensed of an oral tetravalent rhesus reassortant vaccine for routine immunization of infants against rotavirus. The virus was first identified 25 years ago and is now recognized to be the most common single cause of severe diarrhea throughout the world. Most children suffer at least one infection and reinfection is common. Studies of natural immunity show that breastfeeding may merely delay onset of primary infection and that maternal immunity has little effect-especially in developing countries where onset in early infancy is common. Immunity, furthermore, appears to be serotype-specific. Early attempts to develop a vaccine focused on animal forms of rotavirus. More recent efforts have created human-animal reassortants that have been far more successful.