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Lazar K, Pawelec G, Goelz R, Hamprecht K, Wistuba-Hamprecht K. Frequencies of activated T cell populations increase in breast milk of HCMV-seropositive mothers during local HCMV reactivation. Front Immunol 2024; 14:1258844. [PMID: 38235135 PMCID: PMC10792025 DOI: 10.3389/fimmu.2023.1258844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/01/2023] [Indexed: 01/19/2024] Open
Abstract
Background Human cytomegalovirus (HCMV) can reactivate in the mammary gland during lactation and is shed into breast milk of nearly every HCMV-IgG-seropositive mother of a preterm infant. Dynamics of breast milk leukocytes during lactation, as well as blood leukocytes and the comparison between both in the context of HCMV reactivation is not well understood. Methods Here, we present the BlooMil study that aimed at comparing changes of immune cells in blood and breast milk from HCMV-seropositive- vs -seronegative mothers, collected at four time ranges up to two months post-partum. Viral load was monitored by qPCR and nested PCR. Multiparameter flow cytometry was used to identify leukocyte subsets. Results CD3+ T cell frequencies were found to increase rapidly in HCMV-seropositive mothers' milk, while they remained unchanged in matched blood samples, and in both blood and breast milk of HCMV-seronegatives. The activation marker HLA-DR was more strongly expressed on CD4+ and CD8+ T cells in all breast milk samples than matched blood samples, but HCMV-seropositive mothers displayed a significant increase of HLA-DR+ CD4+ and HLA-DR+ CD8+ T cells during lactation. The CD4+/CD8+ T cell ratio was lower in breast milk of HCMV-seropositive mothers than in the blood. HCMV-specific CD8+ T cell frequencies (recognizing pp65 or IE1) were elevated in breast milk relative to blood, which might be due to clonal expansion of these cells during local HCMV reactivation. Breast milk contained very low frequencies of naïve T cells with no significant differences depending on serostatus. Conclusion Taken together, we conclude that the distribution of breast milk leukocyte populations is different from blood leukocytes and may contribute to the decrease of breast milk viral load in the late phase of HCMV reactivation in the mammary gland.
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Affiliation(s)
- Katrin Lazar
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Graham Pawelec
- Department of Immunology, Interfaculty Institute for Cell Biology, University of Tübingen, Tübingen, Germany
- Cancer Solutions Program, Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Rangmar Goelz
- Department of Neonatology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Klaus Hamprecht
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Kilian Wistuba-Hamprecht
- Department of Immunology, Interfaculty Institute for Cell Biology, University of Tübingen, Tübingen, Germany
- Section for Clinical Bioinformatics, Internal Medicine I, University Medical Center, Tübingen, Germany
- M3 Research Center, University Medical Center, Tübingen, Germany
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Francese R, Peila C, Donalisio M, Lamberti C, Cirrincione S, Colombi N, Tonetto P, Cavallarin L, Bertino E, Moro GE, Coscia A, Lembo D. Viruses and Human Milk: Transmission or Protection? Adv Nutr 2023; 14:1389-1415. [PMID: 37604306 PMCID: PMC10721544 DOI: 10.1016/j.advnut.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023] Open
Abstract
Human milk (HM) is considered the best source of nutrition for infant growth and health. This nourishment is unique and changes constantly during lactation to adapt to the physiological needs of the developing infant. It is also recognized as a potential route of transmission of some viral pathogens although the presence of a virus in HM rarely leads to a disease in an infant. This intriguing paradox can be explained by considering the intrinsic antiviral properties of HM. In this comprehensive and schematically presented review, we have described what viruses have been detected in HM so far and what their potential transmission risk through breastfeeding is. We have provided a description of all the antiviral compounds of HM, along with an analysis of their demonstrated and hypothesized mechanisms of action. Finally, we have also analyzed the impact of HM pasteurization and storage methods on the detection and transmission of viruses, and on the antiviral compounds of HM. We have highlighted that there is currently a deep knowledge on the potential transmission of viral pathogens through breastfeeding and on the antiviral properties of HM. The current evidence suggests that, in most cases, it is unnecessarily to deprive an infant of this high-quality nourishment and that the continuation of breastfeeding is in the best interest of the infant and the mother.
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Affiliation(s)
- Rachele Francese
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Chiara Peila
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Manuela Donalisio
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Cristina Lamberti
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Simona Cirrincione
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Nicoletta Colombi
- Biblioteca Federata di Medicina "Ferdinando Rossi", University of Turin, Turin, Italy
| | - Paola Tonetto
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Laura Cavallarin
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Enrico Bertino
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Guido E Moro
- Italian Association of Human Milk Banks (AIBLUD), Milan, Italy.
| | - Alessandra Coscia
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy.
| | - David Lembo
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy.
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3
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Kohda C, Ino S, Ishikawa H, Kuno Y, Nagashima R, Iyoda M. The essential role of intestinal microbiota in cytomegalovirus reactivation. Microbiol Spectr 2023; 11:e0234123. [PMID: 37754566 PMCID: PMC10581228 DOI: 10.1128/spectrum.02341-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/10/2023] [Indexed: 09/28/2023] Open
Abstract
Human cytomegalovirus (HCMV) is a member of Herpesviridae. It has been reported that HCMV is reactivated in the breast milk of HCMV-seropositive lactating women. As we have reported various aspects of the roles of indigenous microbiota, its role in the murine CMV (MCMV) reactivation was examined in this study. MCMV was latently infected in the salivary gland, mammary tissues, and colon in the pregnant mice. When the salivary gland, mammary tissues, and colon were removed 5 days after delivery, MCMV reactivation of latent infection in each organ was confirmed by the detection of MCMV IE1 mRNA using reverse transcription-quantitative PCR. MCMV reactivation was observed in 100% of the mice during pregnancy. Next, for the elimination of intestinal microbiota, the pregnant mice were treated with low-dose or high-dose non-absorbable antibiotics. Although the numbers of aerobe/anaerobe in cecal content in low-dose antibiotic-treated mice were comparable to those in untreated controls, high-dose antibiotic treatment decreased the number of aerobe/anaerobe microbes from ca.9.0 Log10 to ca.3.0 Log10 (cfu/g). However, it could not be confirmed in 16S rRNA analysis that specific bacterial phylum or genus was eliminated by this high-dose treatment. Interestingly, MCMV reactivation was also observed in 100% of low-dose antibiotic-treated mice, whereas, in high-dose antibiotic-treated mice, MCMV reactivation was not observed in the salivary gland or colon. MCMV IE1 mRNA was detected only in 33% of the mammary tissues of those high-dose-treated mice. These results suggest that the indigenous microbiota played a crucial role in the reactivation of latent infection. IMPORTANCE Human cytomegalovirus (HCMV) infection via breast milk is a serious problem for very preterm infants such as developing a sepsis-like syndrome, cholestasis, or bronchopulmonary dysplasia, among others. It has been reported that HCMV is reactivated in the breast milk of HCMV-seropositive lactating women. In this study, the roles of indigenous microbiota in the murine CMV (MCMV) reactivation were examined using a mouse model. In MCMV latently infected mice, MCMV reactivation was observed in 100% of the mice during pregnancy. For the elimination of intestinal microbiota, MCMV-latent mice were treated with non-absorbable antibiotics. After delivery, MCMV reactivation was not observed in antibiotic-treated mice. This result suggested that the indigenous microbiota played a crucial role in the reactivation of latent infection.
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Affiliation(s)
- Chikara Kohda
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Ino
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroki Ishikawa
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
| | - Yoshihiro Kuno
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Ryuichi Nagashima
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
| | - Masayuki Iyoda
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
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Wunderlich W, Sidebottom AC, Schulte AK, Taghon J, Dollard S, Hernandez-Alvarado N. The Use of Saliva Samples to Test for Congenital Cytomegalovirus Infection in Newborns: Examination of False-Positive Samples Associated with Donor Milk Use. Int J Neonatal Screen 2023; 9:46. [PMID: 37606483 PMCID: PMC10443263 DOI: 10.3390/ijns9030046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/20/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
A universal screening research study was conducted in six hospitals to identify the clinical sensitivity of polymerase chain reaction (PCR) testing on newborn dried blood spots (DBSs) versus saliva specimens for the diagnosis of congenital cytomegalovirus (cCMV). CMV DNA positive results from DBSs or saliva were confirmed with urine testing. Findings of several false-positive (FP) saliva PCR results prompted an examination of a possible association with donor milk. Documentation of the frequency of positive saliva results, including both true-positive (TP) and FP status from clinical confirmation, occurred. The frequency of donor milk use was compared for TP and FP cases. Of 22,079 participants tested between 2016 and 2022, 96 had positive saliva results, 15 were determined to be FP, 79 TP, and 2 were excluded for incomplete clinical evaluation. Newborn donor milk use was identified for 18 (19.14%) of all the positive saliva screens. Among the 15 FPs, 11 (73.33%) consumed donor milk compared to 7 of the 79 TPs (8.8%) (OR 28.29, 95% CI 7.10-112.73, p < 0.001). While milk bank Holder pasteurization inactivates CMV infectivity, CMV DNA may still be detectable. Due to this possible association, screening programs that undertake testing saliva for CMV DNA may benefit from documenting donor milk use as a potential increased risk for FP results.
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Affiliation(s)
- Whitney Wunderlich
- Care Delivery Research, Allina Health, Minneapolis, MN 55410, USA; (A.C.S.); (A.K.S.); (J.T.)
| | - Abbey C. Sidebottom
- Care Delivery Research, Allina Health, Minneapolis, MN 55410, USA; (A.C.S.); (A.K.S.); (J.T.)
| | - Anna K. Schulte
- Care Delivery Research, Allina Health, Minneapolis, MN 55410, USA; (A.C.S.); (A.K.S.); (J.T.)
| | - Jessica Taghon
- Care Delivery Research, Allina Health, Minneapolis, MN 55410, USA; (A.C.S.); (A.K.S.); (J.T.)
| | - Sheila Dollard
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA;
| | - Nelmary Hernandez-Alvarado
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA;
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5
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Chung ML, Sung H, Jung E, Lee BS, Kim KS, Kim EAR. Prevention of human milk-acquired cytomegalovirus infection in very-low-birth-weight infants. BMC Pediatr 2023; 23:244. [PMID: 37202724 DOI: 10.1186/s12887-023-04044-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/27/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The aim of the study was to determine the rate of cytomegalovirus virolactia in the human milk (HM) of mothers of VLBW infants, compare the CMV infection rates and the changes in CMV DNA viral load and nutrient profile among different HM preparation methods. METHODS A prospective randomized controlled study was performed in infants with gestational age < 32 weeks or birth-weight < 1500 g admitted to neonatal intensive care unit of Asan Medical Center and Haeundae Paik Hospital who were given mother's own milk. Enrolled infants were randomized into three groups according to the HM preparation methods: freezing-thawing (FT), FT + low-temperature Holder pasteurization (FT + LP), and FT + high-temperature short-term pasteurization (FT + HP). Urine CMV culture and PCR were obtained at birth and at 4, 8, and 12 weeks. HM CMV culture and PCR were obtained at birth and at 3, 6, 9, and 12 weeks. Changes in macronutrients in HM was obtained at 4 ~ 6 weeks. RESULTS Of 564 infants, 217 mothers (38.5%) produced CMV PCR positive milk. After exclusion, a total of 125 infants were randomized into the FT (n = 41), FT + LP (n = 42), and FT + HP (n = 42) groups, whose rate of HM-acquired CMV infection was 4.9% (n = 2), 9.5% (n = 4), and 2.4% (n = 1), respectively. Out of seven CMV infected infants, two infants fed with FT + LP HM developed CMV infection- associated symptoms. Ages at diagnoses were earlier (28.5 days after birth) and at younger post conceptional age (< 32 weeks) in comparison to infants with asymptomatic CMV infection. CMV DNA viral load significantly decreased after pasturizations, especially in FT + HP group. CONCLUSIONS HM-acquired symptomatic CMV infection rate is low and its impact on clinical course was not serious in our VLBW infants. However, evidences showing poor neurodevelopmental outcome in later life, we need to generate a guideline to protect VLBW infant form HM transmitted CMV infection. Based on our small sized study, we did not find any superiority in pasteurizing HM with frequently used LP in comparison to frozen or HP HM. More research is needed to determine the method and duration of pasteurization to reduce the HM-acquired CMV infection.
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Affiliation(s)
- Mi Lim Chung
- Department of Pediatrics, University of Inje College of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Euiseok Jung
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Byong Sop Lee
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Ki Soo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea.
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6
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Kasai R, Toriyabe K, Goto T, Hatano M, Kondo Y, Ohta T, Suyama M, Goto T, Koide W, Maki K, Ushijima K, Ban K. A case of breast milk-acquired cytomegalovirus infection in an extremely low birth weight infant. J Neonatal Perinatal Med 2023:NPM221130. [PMID: 37182845 DOI: 10.3233/npm-221130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Although breast milk is considered the optimal nutrition for infants, it is also the primary cause of postnatal cytomegalovirus (CMV) infection. Preterm infants with postnatal CMV infections are susceptible to a variety of life-threatening conditions. CASE SUMMARY Twin male infants were delivered via emergency caesarian section at 27 weeks' gestation secondary to maternal complete uterine rupture. The Apgar scores at 1 and 5 min were 1 and 1 for the older twin (Twin A) and 0 and 3 for the younger twin (Twin B). Their birth weights were 1203 g (+ 0.65SD) and 495 g (- 3.79SD) respectively. On day 41, laboratory blood test results for Twin B showed a moderate elevation in C-reactive protein (CRP), thrombocytopenia. CMV quantitative polymerase chain reaction (qPCR) tests in Twin B's urine and blood as well as in the mother's breast milk were positive, but stored, dried umbilical cord CMV qPCR tests were negative. Twin B was diagnosed with a postnatal CMV infection secondary to infected breast milk and ganciclovir was commenced on day 52. Treatment was switched to valganciclovir at 74 days of age, but a negative CMV-DNA level in the blood was not achieved. Postnatal CMV infection in this infant led to an exacerbation of pre-existing bronchopulmonary dysplasia (BPD) and he demised at 182 days of age. CONCLUSION Postnatal cytomegalovirus infections may lead to exacerbations of BPD. Early use of raw breast milk in preterm infants should be done with careful consideration of this potential complication.
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Affiliation(s)
- R Kasai
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - K Toriyabe
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Japan
| | - T Goto
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - M Hatano
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - Y Kondo
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - T Ohta
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - M Suyama
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - T Goto
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - W Koide
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - K Maki
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - K Ushijima
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
| | - K Ban
- Department of Pediatrics, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, Japan
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7
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Ogawa R, Kasai A, Hiroma T, Tozuka M, Inaba Y, Nakamura T. Prospective cohort study for postnatal cytomegalovirus infection in preterm infants. J Obstet Gynaecol Res 2023. [PMID: 36890689 DOI: 10.1111/jog.15628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/20/2023] [Indexed: 03/10/2023]
Abstract
AIM Cytomegalovirus (CMV) is a virus that can cause congenital and postnatal infections. Postnatal CMV is mainly transmitted via breast milk and blood transfusions. Frozen-thawed breast milk is used to prevent postnatal CMV infection. A prospective cohort study was conducted to determine the infection rate, risk, and clinical findings of postnatal CMV infection. METHODS This prospective cohort study included infants born at 32 weeks or earlier than the gestational age (GA). Participants were prospectively screened for infection in the urine by performing urine CMV DNA tests twice, that is, once within the first 3 weeks of life and again after 35 weeks postmenstrual age (PMA). Postnatal CMV infection was defined as a case of CMV negative tests within 3 weeks of birth and CMV positive tests after 35 weeks PMA. CMV-negative blood products were used for transfusions in all cases. RESULTS A total of 139 patients were subjected to two urine CMV DNA tests. The prevalence of postnatal CMV infection was 5.0%. One patient died of sepsis-like syndrome. The risk factors of postnatal CMV infection were younger GA and older age of the mother. The characteristic clinical findings of postnatal CMV infection were pneumonia. CONCLUSIONS Frozen-thawed breast milk feeding is not fully effective in preventing postnatal CMV infection. The prevention of postnatal CMV infection is important to further improve the survival rate of preterm infants. Development of guidelines on breast milk feeding for the prevention of postnatal CMV infection is necessary in Japan.
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Affiliation(s)
- Ryo Ogawa
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan.,Graduate School of Medicine Science and Technology, Shinshu University, Nagano, Japan.,Life Science Research Center, Nagano Children's Hospital, Nagano, Japan
| | - Ayaka Kasai
- Graduate School of Medicine Science and Technology, Shinshu University, Nagano, Japan.,Division of Clinical Laboratory, Nagano Children's Hospital, Nagano, Japan
| | - Takehiko Hiroma
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan.,Life Science Research Center, Nagano Children's Hospital, Nagano, Japan
| | - Minoru Tozuka
- Life Science Research Center, Nagano Children's Hospital, Nagano, Japan.,Division of Clinical Laboratory, Nagano Children's Hospital, Nagano, Japan
| | - Yuji Inaba
- Life Science Research Center, Nagano Children's Hospital, Nagano, Japan.,Division of Neuropediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan.,Life Science Research Center, Nagano Children's Hospital, Nagano, Japan
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8
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Carmona AS, Kakkar F, Gantt S. Perinatal Cytomegalovirus Infection. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:395-411. [PMID: 36465883 PMCID: PMC9684878 DOI: 10.1007/s40746-022-00261-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW There have been recent advances in the field of congenital CMV infection (cCMV) related to antiviral treatment of pregnant women and infants, the implementation of newborn CMV screening programs, and the frequency and diagnosis of complications among infected children. In addition, postnatal CMV infection (pCMV) is increasingly recognized as a potential cause of long-term sequelae in addition to acute complications among preterm infants, raising important questions related to treatment, and prevention. RECENT FINDINGS High-dose valacyclovir appears to be safe and effective for the prevention of cCMV among women with first-trimester primary CMV infection. New studies reveal high rates of vestibular dysfunction and neuropsychiatric manifestations among children with cCMV. Some studies report associations between pCMV and long-term consequences, including neurodevelopmental delay and bronchopulmonary dysplasia, among very low birth weight infants, in addition to high risk of sepsis and death acutely, which has motivated efforts to eliminate the virus from breast milk by different methods. SUMMARY More long-term complications of cCMV are increasingly recognized among children previously thought to be asymptomatic. Although a preventive CMV vaccine may be achievable, strategies to reduce the burden of cCMV disease include maternal education about risk-reduction behaviors, antiviral treatment of pregnant women with primary infection, and newborn screening to allow timely, appropriate care. Similarly, although it remains unclear if pCMV causes long-term problems, there is growing interest in identifying and preventing disease from CMV infections among preterm infants.
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Affiliation(s)
- Alejandra Sandoval Carmona
- Department of Pediatrics, 3175 Ch. de La Côte-Sainte-Catherine, Université de Montréal, Montréal, Canada
| | - Fatima Kakkar
- Department of Pediatrics, 3175 Ch. de La Côte-Sainte-Catherine, Université de Montréal, Montréal, Canada
- Centre de Recherche du CHU Sainte-Justine, 3175 Ch. de La Côte-Sainte-Catherine, Montréal, Canada
| | - Soren Gantt
- Department of Pediatrics, 3175 Ch. de La Côte-Sainte-Catherine, Université de Montréal, Montréal, Canada
- Centre de Recherche du CHU Sainte-Justine, 3175 Ch. de La Côte-Sainte-Catherine, Montréal, Canada
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9
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Hu X, Hu W, Sun X, Chen L, Luo X. Transmission of cytomegalovirus via breast milk in low birth weight and premature infants: a systematic review and meta-analysis. BMC Pediatr 2021; 21:520. [PMID: 34809592 PMCID: PMC8607598 DOI: 10.1186/s12887-021-02984-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to investigate the transmission of cytomegalovirus (CMV) via breast milk in low birth weight (LBW) and premature infants and its effects. Methods PubMed, Medline, Cochrane Library, and Embase were searched for studies (without language and time restriction) published before March 27, 2020, that examined the effect of CMV transmitted by breast milk on LBW and premature infants. The rates of breast milk-acquired CMV infection, CMV-related symptoms, and CMV-related sepsis-like syndrome (CMV-SLS) in LBW and premature infants were pooled from each study. Results Eighteen studies with 1920 LBW and premature infants were included. The pooled CMV infection rate from breast milk for infants fed untreated breast milk was significantly higher than those fed frozen breast milk [19.3, 95% confidence interval (CI) = 11.8–29.9% vs. 13.5, 95% CI = 8.0–22.0%, P < 0.01). Similarly, the pooled CMV infection rate for infants fed untreated breast milk was significantly higher than those with mixed feeding (P < 0.0001). The mixed feeding group had a significantly lower rate of CMV-related symptoms than the other groups (2.4%, P < 0.01). Conclusions These findings suggested a higher CMV infection rate in LBW or premature infants fed untreated breast milk than other feeding groups. Studies on the long-term outcomes of CMV infection transmitted from breast milk are needed to address the optimal feeding practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02984-7.
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Affiliation(s)
- Xiaolin Hu
- Pediatric Department, Tongji Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Hu
- Pediatric Department, Tongji Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Sun
- Pediatric Department, Tongji Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Chen
- Pediatric Department, Tongji Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Luo
- Pediatric Department, Tongji Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, Wuhan, China.
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10
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Clinical, Virologic and Immunologic Correlates of Breast Milk Acquired Cytomegalovirus (CMV) Infections in Very Low Birth Weight (VLBW) Infants in a Newborn Intensive Care Unit (NICU) Setting. Viruses 2021; 13:v13101897. [PMID: 34696327 PMCID: PMC8539954 DOI: 10.3390/v13101897] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 01/01/2023] Open
Abstract
Cytomegalovirus (CMV) infections acquired by very-low-birthweight (VLBW) infants are incompletely characterized. To examine CMV transmission in VLBW infants, we evaluated maternal DNAlactia, infant DNAemia, and presence of clinical disease in a blinded study in VLBW infants in our newborn intensive care unit (NICU). To examine these issues, 200 VLBW infants were enrolled in a surveillance study, with weekly breast milk and infant whole blood samples collected, as available. Virologic (breast milk and infant whole blood real time PCR) and immunologic (IgG, IgM, and IgG avidity) correlates were evaluated. A chart review examined whether infants had symptoms compatible with CMV disease. DNAlactia was identified in 65/150 (43%) of lactating mothers. Nine CMV infections were identified in 9/75 CMV-exposed infants (12% of exposed infants). A higher median breast milk viral load (DNAlactia) correlated with an increased likelihood of DNAemia (p = 0.05). Despite potential symptoms compatible with CMV infection, clinicians had not considered the diagnosis of CMV in 6/9 cases (66%). All of these infants had chronic lung disease at discharge. There was no correlation between IgG antibody titer or IgG avidity index and the likelihood of transmission or CMV disease. In conclusion, in VLBW infants receiving milk from seropositive mothers, CMV infections are commonly acquired, and are frequently unrecognized. Future studies are needed to determine whether routine surveillance for CMV of either breast milk or infant plasma is beneficial in preventing or recognizing infection.
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Park HW, Cho MH, Bae SH, Lee R, Kim KS. Incidence of Postnatal CMV Infection among Breastfed Preterm Infants: a Systematic Review and Meta-analysis. J Korean Med Sci 2021; 36:e84. [PMID: 33783146 PMCID: PMC8007418 DOI: 10.3346/jkms.2021.36.e84] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/14/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis to evaluate the incidence of breast milk-acquired cytomegalovirus (CMV) infection in preterm infants born to CMV-seropositive mothers. METHODS PubMed, Embase, and Cochrane Library databases were searched using the terms: ("breast feeding" or "breast milk" or "human milk" or "breast") and ("HCMV" or "cytomegalovirus") and ("infant, extremely premature" or "premature birth" or "newborn" or "neonate" or "low birth weight" or "very low birth weight" or "premature" or "preterm infant"). Studies that had information on CMV status and breast feeding were included in the meta-analysis. RESULTS A total of 2,502 newborns from 19 studies were included in this meta-analysis. The rate of postnatally acquired CMV infection among breastfed infants with CMV-seropositive mothers was 16.5% (95% confidence interval [CI], 0.10-0.26; P < 0.001). The infection rate was 26% with fresh breast milk, 8% with a combined diet of fresh and freeze-thawed breast milk, and 11% with freeze-thawed breast milk. Among cases where the CMV status of breast milk was determined, CMV shedding into breast milk occurred in 80.5% (95% CI, 0.71-0.87; P < 0.001) of CMV seropositive mothers. The breast milk-acquired CMV infection rate among infants fed CMV-positive breast milk was 20.7% (95% CI, 0.14-0.30; P < 0.001). CONCLUSION This meta-analysis examined the rate of breast milk-acquired CMV infections in preterm infants with CMV-seropositive mothers; the CMV infection rate was higher in preterm infants fed fresh breast milk. Until further data are available, we cautiously suggest the use of freeze-thawed breast milk, rather than fresh breast milk, for preterm infants or very low birth weight infants.
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Affiliation(s)
- Hye Won Park
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
- Konkuk University School of Medicine, Seoul, Korea.
| | - Myung Hyun Cho
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sun Hwan Bae
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
- Konkuk University School of Medicine, Seoul, Korea
| | - Ran Lee
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
- Konkuk University School of Medicine, Seoul, Korea
| | - Kyo Sun Kim
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
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12
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Centeno-Tablante E, Medina-Rivera M, Finkelstein JL, Herman HS, Rayco-Solon P, Garcia-Casal MN, Rogers L, Ghezzi-Kopel K, Zambrano Leal MP, Andrade Velasquez JK, Chang Asinc JG, Peña-Rosas JP, Mehta S. Update on the Transmission of Zika Virus Through Breast Milk and Breastfeeding: A Systematic Review of the Evidence. Viruses 2021; 13:v13010123. [PMID: 33477428 PMCID: PMC7830280 DOI: 10.3390/v13010123] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022] Open
Abstract
We systematically searched regional and international databases and screened 1658 non-duplicate records describing women with suspected or confirmed ZIKV infection, intending to breastfeed or give breast milk to an infant to examine the potential of mother-to-child transmission of Zika virus (ZIKV) through breast milk or breastfeeding-related practices. Fourteen studies met our inclusion criteria and inform this analysis. These studies reported on 97 mother-children pairs who provided breast milk for ZIKV assessment. Seventeen breast milk samples from different women were found positive for ZIKV via RT-PCR, and ZIKV replication was found in cell cultures from five out of seven breast milk samples from different women. Only three out of six infants who had ZIKV infection were breastfed, no evidence of clinical complications was found to be associated with ZIKV RNA in breast milk. This review updates our previous report by including 12 new articles, in which we found no evidence of ZIKV mother-to-child transmission through breast milk intake or breastfeeding. As the certainty of the present evidence is low, additional studies are still warranted to determine if ZIKV can be transmitted through breastfeeding.
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Affiliation(s)
- Elizabeth Centeno-Tablante
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (E.C.-T.); (M.M.-R.); (J.L.F.); (H.S.H.)
| | - Melisa Medina-Rivera
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (E.C.-T.); (M.M.-R.); (J.L.F.); (H.S.H.)
| | - Julia L. Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (E.C.-T.); (M.M.-R.); (J.L.F.); (H.S.H.)
| | - Heather S. Herman
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (E.C.-T.); (M.M.-R.); (J.L.F.); (H.S.H.)
| | - Pura Rayco-Solon
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva CH-1211, Switzerland;
| | - Maria Nieves Garcia-Casal
- Department of Nutrition and Food Safety, World Health Organization, Geneva, CH-1211, Switzerland; (M.N.G.-C.); (L.R.); (J.P.P.-R.)
| | - Lisa Rogers
- Department of Nutrition and Food Safety, World Health Organization, Geneva, CH-1211, Switzerland; (M.N.G.-C.); (L.R.); (J.P.P.-R.)
| | | | - Mildred P. Zambrano Leal
- Hospital de Niños Roberto Gilbert Elizalde, Guayaquil 090514, Ecuador; (M.P.Z.L.); (J.K.A.V.); (J.G.C.A.)
| | - Joyce K. Andrade Velasquez
- Hospital de Niños Roberto Gilbert Elizalde, Guayaquil 090514, Ecuador; (M.P.Z.L.); (J.K.A.V.); (J.G.C.A.)
| | - Juan G. Chang Asinc
- Hospital de Niños Roberto Gilbert Elizalde, Guayaquil 090514, Ecuador; (M.P.Z.L.); (J.K.A.V.); (J.G.C.A.)
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, CH-1211, Switzerland; (M.N.G.-C.); (L.R.); (J.P.P.-R.)
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (E.C.-T.); (M.M.-R.); (J.L.F.); (H.S.H.)
- Correspondence:
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13
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Volder C, Work BJ, Hoegh SV, Eckhardt MC, Zachariassen G. Transmission of cytomegalovirus in fresh and freeze-thawed mother's own milk to very preterm infants: a cohort study. J Perinatol 2021; 41:1873-1878. [PMID: 34155328 PMCID: PMC8216583 DOI: 10.1038/s41372-021-01129-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The objectives of the study were to clarify: (i) the frequency of human cytomegalovirus (HCMV) transmission, (ii) the association between the viral load in mother's own milk (MOM), the amount of fresh MOM and transmission, and (iii) the frequency of sepsis-like-symptoms (SLS) among infants born to seropositive mothers compared to infants born to seronegative mothers. STUDY DESIGN This prospective cohort study enrolled very preterm infants (gestational age <32 weeks) from Denmark. Weekly samples of fresh MOM and urine were analyzed for HCMV-DNA. RESULTS Twenty-six very preterm infants were enrolled. Four acquired an HCMV infection, of which two developed SLS. HCMV-infected infants received MOM with a significant higher viral load compared to the HCMV-uninfected infants. CONCLUSION A combination of a high viral load and an increased amount of fresh MOM increased the risk of HCMV transmission. SLS was only slightly more common among infants exposed to HCMV positive MOM.
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Affiliation(s)
- Christina Volder
- grid.10825.3e0000 0001 0728 0170Institute of Clinical Research, University of Southern Denmark, Odense, Denmark ,grid.7143.10000 0004 0512 5013OPEN—Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark
| | - Benedicte Juul Work
- grid.10825.3e0000 0001 0728 0170Institute of Clinical Research, University of Southern Denmark, Odense, Denmark ,grid.7143.10000 0004 0512 5013OPEN—Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark
| | - Silje Vermedal Hoegh
- grid.7143.10000 0004 0512 5013Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Maria-Christina Eckhardt
- grid.7143.10000 0004 0512 5013H.C. Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - Gitte Zachariassen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark. .,OPEN-Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark. .,H.C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
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14
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Prendergast AJ, Goga AE, Waitt C, Gessain A, Taylor GP, Rollins N, Abrams EJ, Lyall EH, de Perre PV. Transmission of CMV, HTLV-1, and HIV through breastmilk. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 3:264-273. [PMID: 30878119 DOI: 10.1016/s2352-4642(19)30024-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 12/14/2022]
Abstract
Breastfeeding is a crucial child survival intervention. However, the potential for transmission of viral infections from mother to child presents the dilemma of how best to interpret the benefits and risks of breastfeeding in different settings. In this Review, we compare the transmission dynamics, risk factors, and outcomes of infection with three chronic viruses transmitted through breastmilk: cytomegalovirus, human T-cell lymphotropic virus type 1, and HIV. We provide an overview of intervention approaches and discuss scientific, policy, and programming gaps in the understanding of these major global infections.
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Affiliation(s)
- Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
| | - Ameena E Goga
- South African Medical Research Council, Cape Town, South Africa; Department of Paediatrics, University of Pretoria, Hatfield, South Africa
| | - Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - E Hermione Lyall
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infection, INSERM, University Montpellier, Etablissement Français du Sang, CHU de Montpellier, Montpellier, France
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15
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Kadambari S, Whittaker E, Lyall H. Postnatally acquired cytomegalovirus infection in extremely premature infants: how best to manage? Arch Dis Child Fetal Neonatal Ed 2020; 105:334-339. [PMID: 31615830 DOI: 10.1136/archdischild-2019-317650] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/03/2019] [Accepted: 09/15/2019] [Indexed: 12/12/2022]
Abstract
Postnatal cytomegalovirus (pCMV) infection is a common viral infection typically occurring within the first months of life. pCMV refers to postnatal acquisition of CMV rather than postnatal manifestations of antenatal or perinatal acquired CMV. pCMV is usually asymptomatic in term infants, but can cause symptomatic disease in preterm (gestational age <32 weeks) and very low birth weight (<1500 g) infants resulting in sepsis, pneumonia, thrombocytopaenia, neutropaenia, hepatitis, colitis and occasionally death. There are significant uncertainties regarding the management of premature infants with pCMV disease which is in part due to our limited understanding of the natural history of this disease. This review describes the current epidemiology and clinical manifestations of pCMV disease which should alert clinicians to test for CMV and also outlines a strategy to manage the condition.
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Affiliation(s)
- Seilesh Kadambari
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, U.K
| | - Elizabeth Whittaker
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, U.K.,Department of Academic Paediatrics, Imperial College, 2nd Floor Wright-Fleming Building, London, U.K
| | - Hermione Lyall
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, U.K
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16
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Ross SA, Michaels MG, Ahmed A, Palmer AL, Sánchez PJ, Bernstein DI, Feja K, Stewart A, Boppana SB, Fowler KB. Contribution of Breastfeeding to False-Positive Saliva Polymerase Chain Reaction for Newborn Congenital Cytomegalovirus Screening. J Infect Dis 2019; 217:1612-1615. [PMID: 29401303 DOI: 10.1093/infdis/jiy057] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 11/14/2022] Open
Abstract
Real-time polymerase chain reaction (PCR) of saliva is highly sensitive for newborn congenital cytomegalovirus (CMV) screening. This study uses nationally published CMV seroprevalence and breastfeeding rates to estimate the contribution of CMV DNA in breast milk to false-positive saliva PCR results. The false-positive rates adjusted for breastfeeding ranged from 0.03% in white Hispanic persons to 0.14% in white non-Hispanic persons. Saliva CMV PCR for newborn screening is highly sensitive, and the low false-positive rates in this study suggest that saliva PCR results are unlikely to be significantly influenced by breastfeeding or other perinatal exposures.
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Affiliation(s)
- Shannon A Ross
- Department of Pediatrics, Philadelphia, Pennsylvania.,Department of Microbiology, Philadelphia, Pennsylvania
| | - Marian G Michaels
- Department of Pediatrics, University of Pittsburgh and the Children's Hospital of Pittsburgh of UPMC, Philadelphia, Pennsylvania
| | - Amina Ahmed
- Department of Pediatrics, Carolinas Medical Center, Charlotte, North Carolina
| | - April L Palmer
- Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - David I Bernstein
- Cincinnati Children's Hospital Medical Center and University of Cincinnati
| | - Kristina Feja
- Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Audra Stewart
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Suresh B Boppana
- Department of Pediatrics, Philadelphia, Pennsylvania.,Department of Microbiology, Philadelphia, Pennsylvania
| | - Karen B Fowler
- Department of Pediatrics, Philadelphia, Pennsylvania.,Department of Epidemiology, University of Alabama at Birmingham, Philadelphia, Pennsylvania
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17
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Bardanzellu F, Fanos V, Reali A. Human Breast Milk-acquired Cytomegalovirus Infection: Certainties, Doubts and Perspectives. Curr Pediatr Rev 2019; 15:30-41. [PMID: 30474531 PMCID: PMC6696824 DOI: 10.2174/1573396315666181126105812] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/30/2018] [Accepted: 11/14/2018] [Indexed: 01/19/2023]
Abstract
Breast Milk (BM) is the best source of nutrition for newborns, especially if premature. In fact, its beneficial impact on short- and the long-term neonatal outcome has was deeply described. Unfortunately, BM could not be always so safe, especially due to the possible presence of maternal viruses that can be shed and transferred to the breastfed neonate. Among these, Cytomegalovirus (CMV) can potentially lead to a serious and acute illness, mostly in case of low gestational age. Some studies also report the association of CMV-acquired infection to an increased risk of structural and functional brain modifications and neurological impairment. Due to these reasons, a strategy to remove CMV from BM with a minimal or absent impact on its beneficial components would be desirable. Up to now, pasteurization, freezing, ultraviolet- C or microwave irradiation are the available techniques; they show different levels of efficacy and variable effects on BM composition, even if many studies are still needed to fully clarify these implications. In this review, we provide an update of the current evidence about these topics. We focus on the factors promoting CMV shedding through BM; moreover, the possible occurrence of a severe disease in preterm neonates is also described. Finally, we investigate the potential effects showed on BM properties by the strategies that prevent or reduce viral transmission, therefore influencing newborns' health, and the new techniques which could show a relevant role in the next future, such as metabolomics.
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Affiliation(s)
- Flaminia Bardanzellu
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Italy
| | - Alessandra Reali
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Italy
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18
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Gang MH, Chang MY. Breast Milk-Transmitted Cytomegalovirus Infection in Preterm Infants. NEONATAL MEDICINE 2018. [DOI: 10.5385/nm.2018.25.2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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19
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Gelemanović A, Dobberpuhl K, Krakar G, Patarčić I, Kolčić I, Polašek O. Host genetics and susceptibility to congenital and childhood cytomegalovirus infection: a systematic review. Croat Med J 2017; 57:321-30. [PMID: 27586547 PMCID: PMC5048223 DOI: 10.3325/cmj.2016.57.321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim To summarize available evidence on the role of host genetics in the susceptibility to congenital and childhood cytomegalovirus (CMV) infections by conducting a systematic review of published studies. Methods We searched online databases (PubMed, Web of Science, Scopus and HuGe Navigator) for relevant studies with well-defined inclusion and exclusion criteria and assessed the risk of bias using novel Confounding-Selection-Information bias score (CSI). Results 5105 studies were initially identified, but only 5 met all the inclusion criteria and were analyzed in detail. Polymorphisms of the toll-like receptors (TLRs) and mannose-binding lectin (MBL) genes were shown to have an impact on the CMV infection in infants. Polymorphisms of the TLR2 (rs3804100, rs1898830), TLR4 (rs4986791), and TLR9 (rs352140) were shown to have a role in congenital CMV infection. Low MBL levels were associated with CMV infection in Chinese individuals, a finding that was not replicated in Caucasians. The overall credibility of evidence was weak. Conclusions Based on currently available very limited amount of evidence, it is uncertain whether congenital and childhood CMV infections are under host genetic control. Additional primary studies are needed with more specific research hypotheses that will enable gradual understanding of specific mechanisms of the CMV pathogenesis. More genetic studies in the future will facilitate better understanding of host susceptibility and likely enable novel preventative and curative measures.
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Affiliation(s)
| | | | | | | | | | - Ozren Polašek
- Ozren Polašek, School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia,
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20
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Hibbs AM, Muhlebach MS. Infection and Inflammation: Catalysts of Pulmonary Morbidity in Bronchopulmonary Dysplasia. RESPIRATORY OUTCOMES IN PRETERM INFANTS 2017. [PMCID: PMC7121702 DOI: 10.1007/978-3-319-48835-6_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio USA
| | - Marianne S. Muhlebach
- Department of Pediatrics, University of North Carolina Chapel Hill, Chapel Hill, North Carolina USA
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21
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Peters MD, McArthur A, Munn Z. Safe management of expressed breast milk: A systematic review. Women Birth 2016; 29:473-481. [DOI: 10.1016/j.wombi.2016.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 05/26/2016] [Accepted: 05/29/2016] [Indexed: 10/21/2022]
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22
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Ran LH, Bao L. [Research advances in breast milk-acquired cytomegalovirus infection in premature infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18. [PMID: 27751206 PMCID: PMC7389540 DOI: 10.7499/j.issn.1008-8830.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Breast milk is considered ideal food for premature infants, but it can also be the main source of cytomegalovirus (CMV) infection in premature infants. CMV infection may cause serious clinical symptoms, such as sepsis-like syndrome, thrombocytopenia, neutropenia, jaundice, hepatitis, and pneumonitis. This article reviews the research advances in symptoms, treatment strategies, prognosis and the prevention of breast milk-acquired CMV infection in premature infants.
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Affiliation(s)
- Li-Hong Ran
- Department of Neonatology, Children's Hospital of Chongqing Medical University, China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China.
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23
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Mukhopadhyay S, Meyer SA, Permar SR, Puopolo KM. Symptomatic Postnatal Cytomegalovirus Testing among Very Low-Birth-Weight Infants: Indications and Outcomes. Am J Perinatol 2016; 33:894-902. [PMID: 27057771 PMCID: PMC6010048 DOI: 10.1055/s-0036-1581080] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective The objective of this study was to describe the indications for postnatal cytomegalovirus (CMV) testing among very low-birth-weight (VLBW, birth weight [BW] < 1,500 g) infants, clinical characteristics of infected infants, and adverse outcomes associated with CMV infection. Study Design This is a single-center, retrospective study of 2,132 VLBW infants from 1999 to 2013. Results In this study, 145 (6.8%) infants out of 2,132 were evaluated for postnatal CMV infection and 27 (18.6%) infants out of 145 were infected. CMV-tested infants were of significantly lower gestational age and BW compared with untested VLBW infants (p < 0.001). Respiratory decompensation and thrombocytopenia were the findings most commonly associated with infection. CMV-infected infants had significantly more exposure to mechanical ventilation and longer duration of hospitalization. Adjusting for multiple predictors of respiratory morbidity, the incidence of bronchopulmonary dysplasia (BPD) was significantly elevated among infants diagnosed with postnatal CMV infection (odds ratio, 4.0 [95% confidence interval, 1.3-12.4); p, 0.02.) Conclusion Symptomatic postnatal CMV infection was diagnosed in 1.3% of VLBW infants, most commonly among infants with BW < 1,000 g with respiratory instability and thrombocytopenia. Similar to late-onset bacterial infection, symptomatic postnatal CMV infection may be an independent contributor to the development of BPD. This possibility should be addressed in a prospective study of extremely low BW infants.
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Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah A. Meyer
- Department of Pediatric Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sallie R. Permar
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina,Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
BACKGROUND Congenital cytomegalovirus (CMV) is the leading viral intrauterine infection in the United States. It causes more developmental delays and long-term sequelae than Down syndrome (trisomy 21), neural tube defects, or fetal alcohol syndrome combined. Yet, this virus, a member of the herpes virus family, is not well known to the public and its prevention is typically not discussed in obstetric offices. Although many infants with congenital CMV are asymptomatic at birth, a significant proportion still may develop sequelae. Symptomatic infants face potentially devastating consequences. Pharmacologic treatment is reserved for those with severe organ or central nervous system involvement. Treatment of infants with congenital CMV can be complex and requires extensive outpatient follow-up. PURPOSE To educate nurses and nurse practitioners regarding the risks, signs, treatment, and care related to congenital CMV. METHODS/SEARCH STRATEGIES PubMed was searched to obtain English language publications from 2005 to 2015 for studies examining the current knowledge base of congenital cytomegalovirus, sequelae, and subsequent treatment using key terms "cytomegalovirus" combined with "congenital." A total of 18 articles were retained for analysis. FINDINGS/RESULTS Overall, the greatest risk reduction strategy for CMV transmission is education of pregnant women. In the neonate at risk for congenital CMV, early identification, antiviral treatment, and care coordination are pivotal to maximizing outcomes. IMPLICATIONS FOR PRACTICE Increasing understanding of congenital CMV, modes of transmission, signs of infection, and intervention strategies as well as its impact on development are essential to maximizing outcomes. IMPLICATIONS FOR RESEARCH The need for research exists in the area of valganciclovir's impact on sensorineural hearing loss as well as potential vaccines to protect against CMV transmission. Research is also being conducted in the area of passive immunity via administration of CMV-specific hyperimmune globulin therapy to pregnant women diagnosed with a primary CMV infection.
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Kelly MS, Benjamin DK, Puopolo KM, Laughon MM, Clark RH, Mukhopadhyay S, Benjamin DK, Smith PB, Permar SR. Postnatal Cytomegalovirus Infection and the Risk for Bronchopulmonary Dysplasia. JAMA Pediatr 2015; 169:e153785. [PMID: 26642118 PMCID: PMC4699399 DOI: 10.1001/jamapediatrics.2015.3785] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Postnatally acquired cytomegalovirus (CMV) is typically benign in term infants but in very low-birth-weight (VLBW) infants can cause pneumonitis and sepsislike illness. Whether postnatal CMV infection results in long-term pulmonary sequelae in these infants is unknown. OBJECTIVE To investigate the association between postnatal CMV infection and bronchopulmonary dysplasia (BPD) and mortality in a large multicenter cohort of VLBW infants. DESIGN, SETTING, AND PARTICIPANTS Conducted between October 2014 and June 2015, this propensity-matched retrospective cohort study involved 101,111 hospitalized VLBW (<1500 g) infants at 348 neonatal intensive care units in the United States from 1997 to 2012. We matched infants with postnatal CMV infection 1:1 to comparison infants using propensity scores, and we used Poisson regression to examine the effect of postnatal CMV on the combined risk for death or BPD at 36 weeks' postmenstrual age. To describe features of postnatal CMV infection, we extracted clinical and laboratory data from 7 days before until 7 days after infants met criteria for postnatal CMV. EXPOSURES Postnatal CMV infection was defined as a diagnosis of CMV or detection of CMV from blood, urine, cerebrospinal fluid, or respiratory secretions on or after day of life 21. Infants with a CMV diagnosis or virologic detection of CMV prior to day of life 21 were not considered to have postnatal infection. MAIN OUTCOMES AND MEASURES The primary outcome was death or BPD at 36 weeks' postmenstrual age. RESULTS Of 101,111 infants, 328 (0.3%) had postnatal CMV infection. We matched a comparison infant to 303 CMV-infected infants (92%) for a final cohort of 606 infants. The median gestational age and birth weight of this cohort were 25 weeks and 730 g, respectively. Postnatal CMV infection was associated with an increased risk for death or BPD at 36 weeks' postmenstrual age (risk ratio, 1.21; 95% CI, 1.10-1.32) and BPD (risk ratio, 1.33; 95% CI, 1.19-1.50). Changes in cardiorespiratory status associated with postnatal CMV infection included a new requirement for vasopressor medications (9%; n = 29), intubation for mechanical ventilation (15%; n = 49), a new oxygen requirement (28%; n = 91), and death (1.2%; n = 4). CONCLUSIONS AND RELEVANCE In VLBW infants, postnatal CMV infection was associated with increased risk for BPD. Further studies are needed to determine the role of preventive measures against CMV in this population.
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Affiliation(s)
- Matthew S Kelly
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina2Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Daniel K Benjamin
- Department of Economics, Clemson University, Clemson, South Carolina
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew M Laughon
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, Florida
| | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina2Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina2Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Sallie R Permar
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
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Yoo HS, Sung SI, Jung YJ, Lee MS, Han YM, Ahn SY, Chang YS, Park WS. Prevention of Cytomegalovirus Transmission via Breast Milk in Extremely Low Birth Weight Infants. Yonsei Med J 2015; 56:998-1006. [PMID: 26069123 PMCID: PMC4479869 DOI: 10.3349/ymj.2015.56.4.998] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Extremely low birth weight infants (ELBWIs) have a high risk of acquiring cytomegalovirus (CMV) infection via breast milk and consequently developing serious symptoms. We evaluated whether freeze-thawing or pasteurization could prevent postnatal CMV infection transmitted through breast milk in ELBWIs. MATERIALS AND METHODS Medical records of 385 ELBWIs with whole milk feeding, and freeze-thawed or pasteurized breast milk feeding were reviewed retrospectively. Postnatally acquired CMV infection was defined as an initial negative and a subsequent positive on follow-up urine CMV DNA polymerase chain reaction screening tests. The incidence, clinical characteristics, symptoms, sequelae, and long-term outcome at corrected age [(CA): 2 years of CMV infection] were analyzed. RESULTS While no infant developed CMV infection with whole milk (0/22) or pasteurized breast milk (0/62) feeding, postnatal CMV infection was diagnosed in 8% (27/301) of ELBWIs who were fed freeze-thawed breast milk. Gestational age in the CMV group was significantly lower than the control group. In 82% (22/27) of cases, CMV infection was symptomatic and was associated with increased ventilator days and ≥moderate bronchopulmonary dysplasia (BPD). Neurodevelopmental outcome and growth status at CA 2 years were not different between the study groups. Lower gestational age and freeze-thawed breast milk feeding >60% of total oral intake during the first 8 postnatal weeks were independent risk factors for acquiring postnatal CMV infection. BPD (≥moderate) was the only significant adverse outcome associated with this CMV infection. CONCLUSION Pasteurization but not freeze-thawing of breast milk eradicated the postnatal acquisition of CMV infection through breast milk.
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Affiliation(s)
- Hye Soo Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Jin Jung
- Department of Pediatrics, Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Myung Sook Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mi Han
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Pilar RGM, Marta C, María Teresa MB, Emilio CB, Cristina S, Natividad P, Jesús M, Félix O. Evaluation of cytomegalovirus infection in low-birth weight children by breast milk using a real-time polymerase chain reaction assay. J Med Virol 2015; 87:845-50. [DOI: 10.1002/jmv.24101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2014] [Indexed: 11/10/2022]
Affiliation(s)
| | - Cabrera Marta
- Neonatal Intensive Care Unit of Hospital; Universitario La Paz, IdiPaz; Madrid Spain
| | | | - Cendejas-Bueno Emilio
- Department of Clinical Microbiology; University Hospital La Paz, IdiPAZ; Madrid Spain
| | - Segovia Cristina
- Neonatal Intensive Care Unit of Hospital; Universitario La Paz, IdiPaz; Madrid Spain
| | - Pastrana Natividad
- Neonatal Intensive Care Unit of Hospital; Universitario La Paz, IdiPaz; Madrid Spain
| | - Mingorance Jesús
- Department of Clinical Microbiology; University Hospital La Paz, IdiPAZ; Madrid Spain
| | - Omeñaca Félix
- Neonatal Intensive Care Unit of Hospital; Universitario La Paz, IdiPaz; Madrid Spain
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Leroy S, M'Zali F, Kann M, Weber DJ, Smith DD. Impact of vaginal-rectal ultrasound examinations with covered and low-level disinfected transducers on infectious transmissions in france. Infect Control Hosp Epidemiol 2014; 35:1497-504. [PMID: 25419772 DOI: 10.1086/678604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The risk of cross-infection from shared ultrasound probes in endorectal and vaginal ultrasonography due to low-level disinfection (LLD) is difficult to estimate because potential infections are also sexually transmitted diseases, and route of contamination is often difficult to establish. In France, the widely used standard for prevention of infections is through the use of probe covers and LLD of the ultrasound transducer by disinfectant wipes. We performed an in silico simulation based on a systematic review to estimate the number of patients infected after endorectal or vaginal ultrasonography examination using LLD for probes. STUDY DESIGN We performed a stochastic Monte Carlo computer simulation to produce hypothetical cohorts for a population of 4 million annual ultrasound examinations performed in France, and we estimated the number of infected patients for human immunodeficiency virus (HIV), herpes simplex virus, hepatitis B virus, hepatitis C virus, human papilloma virus, cytomegalovirus, and Chlamydia trachomatis. Modeling parameters were estimated by meta-analysis when possible. RESULTS The probability of infection from a contaminated probe ranged from 1% to 6%, depending on the pathogen. For cases of HIV infection, this would result in approximately 60 infected patients per year. For other common viral infections, the number of new cases ranged from 1,600 to 15,000 per year that could be attributable directly to ultrasound and LLD procedures. CONCLUSIONS Our simulation results showed that, despite cumulative use of probe cover and LLD, there were still some cases of de novo infection that may be attributable to ultrasound procedures. These cases are preventable by reviewing the currently used LLD and/or upgrading LLD to high-level disinfection, as recommended by the US Centers for Disease Control and Prevention.
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Affiliation(s)
- Sandrine Leroy
- Laboratoire de Biostatistique, Epidémiologie, Santé Publique et Informatique Médicale, Centre Hospitalier Universitaire (CHU) de Nîmes, Nîmes, France; and EA 2415 Unit, Montpellier 1 University, Montpellier, France
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Gunkel J, Wolfs TFW, de Vries LS, Nijman J. Predictors of severity for postnatal cytomegalovirus infection in preterm infants and implications for treatment. Expert Rev Anti Infect Ther 2014; 12:1345-55. [DOI: 10.1586/14787210.2014.966080] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Deere JD, Barry PA. Using the nonhuman primate model of HCMV to guide vaccine development. Viruses 2014; 6:1483-501. [PMID: 24681748 PMCID: PMC4014706 DOI: 10.3390/v6041483] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 12/19/2022] Open
Abstract
The natural history of human cytomegalovirus (HCMV) is inextricably associated with mucosal surfaces. The vast preponderance of primary infections occur following mucosal exposure to infectious virions, and the high seroprevalence of HCMV throughout the world is due to long-term excretion of HCMV in bodily fluids from multiple mucosal sites. Accumulating evidence presents a model where the earliest virus-host interactions following infection dictate the long-term pattern of infection, alter innate immune responses that skew adaptive responses to enable persistence within an immune host, and are essential for reinfection of a host with prior immunity. HCMV has evolved a complex repertoire of viral functions fine-tuned to manipulate the immune environment both locally at the sites of infection and systemically within an infected host. Collectively, viral immune modulation represents a significant impediment for an HCMV vaccine. As HCMV can disseminate beyond mucosal surfaces to reinfect immune hosts, it may not matter whether prior immunity results from prior infection or immunization. A better understanding of the earliest virus-hosts interactions at mucosal surfaces may identify elements of the viral proteome that are especially susceptible to vaccine-mediated disruption and prevent challenge virus from disseminating to distal sites, particularly the maternal-fetal interface.
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Affiliation(s)
- Jesse D Deere
- Center for Comparative Medicine, University of California, Davis, Davis, CA 95616, USA.
| | - Peter A Barry
- Center for Comparative Medicine, Department of Pathology and Laboratory Medicine, California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA.
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Turner KM, Lee HC, Boppana SB, Carlo WA, Randolph DA. Incidence and impact of CMV infection in very low birth weight infants. Pediatrics 2014; 133:e609-15. [PMID: 24488749 PMCID: PMC3934333 DOI: 10.1542/peds.2013-2217] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants. METHODS VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed. RESULTS Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs. 9%, P < .0001) and confirmed at follow-up (83% vs. 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs. 25%, P < .0001) and adverse developmental motor outcomes (43% vs. 9%, P = .02). Acquired CMV was not associated with any adverse outcomes. CONCLUSIONS Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.
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Affiliation(s)
| | - Henry C. Lee
- Division of Neonatology, Stanford University, Palo Alto, California; and
| | - Suresh B. Boppana
- Infectious Diseases, University of Alabama in Birmingham, Birmingham, Alabama
| | | | - David A. Randolph
- Divisions of Neonatology, and,Division of Neonatology, Rocky Mountain Hospital for Children at Presbyterian/St Luke’s Medical Center, Denver, Colorado
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Mehler K, Oberthuer A, Lang-Roth R, Kribs A. High rate of symptomatic cytomegalovirus infection in extremely low gestational age preterm infants of 22-24 weeks' gestation after transmission via breast milk. Neonatology 2014; 105:27-32. [PMID: 24247027 DOI: 10.1159/000355306] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/23/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Very immature preterm infants are at risk of developing symptomatic or severe infection if cytomegalovirus is transmitted via breast milk. It is still a matter of debate whether human cytomegalovirus (HCMV) infection may lead to long-term sequelae. OBJECTIVES We hypothesized that symptomatic and severe HCMV infection transmitted via breast milk affects extremely immature infants at a very high rate. METHODS In 2012, untreated breast milk was fed to extremely low birth weight infants after parental informed consent was obtained. We retrospectively analyzed data on HCMV infection of infants born in 2012 between 22 and 24 weeks of gestation. RESULTS 17 infants were born to HCMV IgG-seropositive mothers. 11 (65%) of these were diagnosed with symptomatic infection. In all cases, thrombocytopenia was the reason to analyze the infant's urine. HCMV infection was diagnosed at a median time of 12 weeks after birth. In 5 (45%) infants, thrombocytopenia was the only symptom and resolved without antiviral therapy or platelet transfusion. 6 (55%) infants developed sepsis-like disease with mildly elevated CRP values and showed signs of respiratory failure. 3 (27%) were able to be stabilized on CPAP, 3 (27%) had to be intubated and mechanically ventilated. 4 children were treated with ganciclovir and/or valganciclovir. 55% failed otoacoustic emissions and/or automated auditory brainstem response testing at discharge. CONCLUSIONS In very immature infants born at the border of viability and suffering from multiple preexisting problems, HCMV infection may trigger a severe deterioration of the clinical course.
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Affiliation(s)
- Katrin Mehler
- Department of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
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El-Sayed MF, Goldfarb DM, Fulford M, Pernica JM. Severe late-onset multisystem cytomegalovirus infection in a premature neonate previously treated for congenital infection. BMC Pediatr 2013; 13:142. [PMID: 24024982 PMCID: PMC3847698 DOI: 10.1186/1471-2431-13-142] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 09/07/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cytomegalovirus is the most common pathogen causing congenital infection and can result in significant neurodevelopmental adverse outcomes. For this reason, it is the standard of care in many regions to treat congenital cytomegalovirus infection involving the brain with six weeks of ganciclovir. There have been no reports in the published literature of significant cytomegalovirus neonatal infection in infants previously treated for congenital infection. CASE PRESENTATION A preterm male infant with congenital symptomatic cytomegalovirus infection was initially treated with over 8 weeks of ganciclovir between the ages of 3 and 14 weeks. At four months chronologic age, just prior to planned discharge, he developed an episode of life-threatening multisystem cytomegalovirus disease notable for severe pneumonitis, encephalitis, hepatitis, and disseminated intravascular coagulation. This disease resolved after re-treatment with a prolonged course of intravenous ganciclovir and oral valganciclovir. CONCLUSIONS Clinicians should be aware of the possibility of recurrence of congenital cytomegalovirus infection, especially in preterm infants. Serial plasma cytomegalovirus viral load monitoring may have a role in the management of premature infants treated with ganciclovir; had the diagnosis of recrudescent cytomegalovirus infection been considered sooner, specific therapy might have been more quickly initiated and perhaps further morbidity would have been prevented.
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Affiliation(s)
- Manal F El-Sayed
- Division of Infectious Disease, Department of Pediatrics, McMaster University, rm 3A-30 1280 Main St, West, Hamilton, ON L8S 4 K1, Canada.
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Álvarez Domínguez E, Figueras Aloy J, Botet Mussons F, Marcos Maeso M, Pérez Fernández J. Cribado de la infección por citomegalovirus en recién nacidos de muy bajo peso. An Pediatr (Barc) 2013; 79:3-9. [DOI: 10.1016/j.anpedi.2012.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 11/25/2022] Open
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Lanzieri TM, Dollard SC, Josephson CD, Schmid DS, Bialek SR. Breast milk-acquired cytomegalovirus infection and disease in VLBW and premature infants. Pediatrics 2013; 131:e1937-45. [PMID: 23713111 PMCID: PMC4850548 DOI: 10.1542/peds.2013-0076] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Very low birth weight (VLBW) and premature infants are at risk for developing postnatal cytomegalovirus (CMV) disease, including CMV-related sepsis-like syndrome (CMV-SLS) for which estimates [corrected] in the United States are lacking. METHODS We performed a systematic review and meta-analysis to estimate the pooled proportions (and 95% confidence intervals) of VLBW and premature infants born to CMV-seropositive women with breast milk-acquired CMV infection and CMV-SLS. We combined these proportions with population-based rates of CMV seropositivity, breast milk feeding, VLBW, and prematurity to estimate annual rates of breast milk-acquired CMV infection and CMV-SLS in the United States. RESULTS In our meta-analysis, among 299 infants fed untreated breast milk, we estimated 19% (11%-32%) acquired CMV infection and 4% (2%-7%) developed CMV-SLS. Assuming these proportions, we estimated a rate of breast milk-acquired CMV infection among VLBW and premature infants in the United States of 6.5% (3.7%-10.9%) and 1.4% (0.7%-2.4%) of CMV-SLS, corresponding to 600 infants with CMV-SLS in 2008. Among 212 infants fed frozen breast milk, our meta-analysis proportions were 13% (7%-24%) for infection and 5% (2%-12%) for CMV-SLS, yielding slightly lower rates of breast milk-acquired CMV infection (4.4%; 2.4%-8.2%) but similar rates of CMV-SLS (1.7%; 0.7%-4.1%). CONCLUSIONS Breast milk-acquired CMV infection presenting with CMV-SLS is relatively rare. Prospective studies to better define the burden of disease are needed to refine guidelines for feeding breast milk from CMV-seropositive mothers to VLBW and premature infants.
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Affiliation(s)
- Tatiana M. Lanzieri
- National Center for Immunization and Respiratory Diseases, Center for Disease Control and Prevention, Atlanta, GA
| | - Sheila C. Dollard
- National Center for Immunization and Respiratory Diseases, Center for Disease Control and Prevention, Atlanta, GA
| | | | - D. Scott Schmid
- National Center for Immunization and Respiratory Diseases, Center for Disease Control and Prevention, Atlanta, GA
| | - Stephanie R. Bialek
- National Center for Immunization and Respiratory Diseases, Center for Disease Control and Prevention, Atlanta, GA
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Narvaez-Arzate RV, Olguin-Mexquitic L, Lima-Rogel V, Noyola DE, Barrios-Compean LM, Villegas-Alvarez C. Cytomegalovirus infection in infants admitted to a neonatal intensive care unit. J Matern Fetal Neonatal Med 2013; 26:1103-6. [PMID: 23356634 DOI: 10.3109/14767058.2013.770459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the incidence of congenital cytomegalovirus (CMV) infection and the frequency of postnatal infection in a neonatal intensive care unit (NICU). METHODS Urine samples of 135 infants who were admitted to the NICU during a 6 month period were evaluated to detect CMV using a nested PCR assay. A breast milk sample was obtained to determine viral excretion. Clinical characteristics of infected and non-infected infants were compared. RESULTS Congenital CMV infection was confirmed in two (1.48%) infants. Post-natal infection was documented in four of 36 (11.1%) infants that were evaluated. CMV excretion was detected in 43 of 116 mothers. Gestational age of infants born to mothers who excreted CMV was shorter than that of infants of mothers with negative results (33.1 versus 34.2 weeks; p = 0.07). CONCLUSIONS CMV excretion in breast milk is frequent and is associated to congenital and postnatal infection. Further studies are necessary to assess the impact of CMV infection during pregnancy and neonatal outcomes.
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Affiliation(s)
- Ricardo V Narvaez-Arzate
- Neonatology Service, Pediatrics Division, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, México
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Lombardi G, Garofoli F, Manzoni P, Stronati M. Breast milk-acquired cytomegalovirus infection in very low birth weight infants. J Matern Fetal Neonatal Med 2012; 25 Suppl 3:57-62. [DOI: 10.3109/14767058.2012.712345] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hsu HT, Fong TV, Hassan NM, Wong HL, Rai JK, Khalid Z. Human milk donation is an alternative to human milk bank. Breastfeed Med 2012; 7:118-22. [PMID: 22011131 DOI: 10.1089/bfm.2011.0006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND AIMS Human milk bank is a source of human milk supply in many neonatal intensive care units. However, there are some hospitals without this facility because of financial or religious impediments, such as the Muslim community. METHODS We introduced human milk donation as an alternative to human milk banking based on Islamic principles. The suitable donor is a healthy rooming-in mother whose expressed breastmilk is in excess of her baby's demand. The milk is used after 72 hours of freezing at -20°C. The donor must fulfill the criteria for selection of donors and be nonreactive to human immunodeficiency virus and syphilis. Once the recipient's family and the donor state their desire for the human milk donation, a meeting with both parties is made. Unpasteurized frozen-thawed donor's milk will be provided to the recipient after written consents are obtained from both parties. RESULTS This study was carried out in the Duchess of Kent Hospital (Sandakan, Sabah, Malaysia) between January 2009 and December 2010. A total of 48 babies received donated breastmilk. Forty-two infants were from the special care nursery, and the remaining six were from the pediatric ward. Eighty-eight percent of the donors and 77% of the recipients were Muslims. Sixty percent of the infants who received donated human milk were premature. Two infants died because of the underlying nature of their disease. CONCLUSION Human milk donation is an option for hospitals without a human milk bank or in the Muslim community.
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Affiliation(s)
- Ho-Torng Hsu
- Department of Pediatrics, Duchess of Kent Hospital, Sandakan, Sabah, Malaysia
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Ehlinger EP, Webster EM, Kang HH, Cangialose A, Simmons AC, Barbas KH, Burchett SK, Gregory ML, Puopolo KM, Puopolo KP, Permar SR. Maternal cytomegalovirus-specific immune responses and symptomatic postnatal cytomegalovirus transmission in very low-birth-weight preterm infants. J Infect Dis 2011; 204:1672-82. [PMID: 21984738 DOI: 10.1093/infdis/jir632] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Transmission of cytomegalovirus (CMV) via breast milk can lead to severe acute illness in very low-birth-weight (VLBW) preterm infants. Although the majority of CMV-seropositive women shed CMV in milk, symptomatic postnatal infection of VLBW infants occurs infrequently, suggesting that virologic or immunologic factors in milk may be associated with the risk and severity of postnatal CMV infection. METHODS We investigated the magnitude of CMV-specific cellular and humoral immune responses in milk of 30 seropositive mothers of VLWB preterm infants and assessed their relationship to milk CMV load and symptomatic CMV transmission. RESULTS Milk immunoglobulin G (IgG) avidity was inversely correlated to milk CMV load (r = -0.47; P = .009). However, milk CMV load and CMV-specific cellular and humoral immune responses were similar in mothers of VLBW infants with and those without symptomatic postnatal CMV infection. CONCLUSIONS Similar immunologic parameters in milk of CMV-seropositive mothers of VLBW infants with and without symptomatic postnatal CMV infection indicate that screening milk by these parameters may not predict disease risk. However, the inverse correlation between milk CMV IgG avidity and CMV load may suggest that enhancement of maternal CMV-specific IgG responses could aid in reduction of CMV shedding into breast milk.
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Affiliation(s)
- Elizabeth P Ehlinger
- Division of Viral Pathogenesis, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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