In the Journals

CMV further linked to necrotizing enterocolitis among NICU patients

Pablo Sanchez 2019
Pablo J. Sanchez

According to research published in The Journal of Pediatrics, during a recent 17-year period, 4% of infants with necrotizing enterocolitis, or NEC, or spontaneous intestinal perforation, or SIP, in one NICU had intestinal infection with cytomegalovirus.

“NEC is a devastating condition in preterm infants that is associated with substantial morbidity and even mortality,” Pablo J. Sanchez, MD, a pediatric neonatologist and infectious disease specialist at Nationwide Children’s Hospital, told Infectious Diseases in Children. “CMV is an increasingly recognized pathogen among infants in the NICU, and postnatally acquired CMV infection has been attributed to ingestion of CMV-containing maternal milk. Trying to understand the potential etiologies of NEC and SIP, and especially [their] possible association with CMV, is important for development of treatment or preventive strategies.”

Sanchez and colleagues conducted a retrospective cohort study in the NICU at Nationwide Children’s Hospital. All infants received diagnoses of NEC (at least Bell stage 2B) or SIP between 2000 and 2016. The researchers tested paraffin-embedded surgical or autopsy intestinal tissues for CMV using PCR and immunohistochemistry (IHC).

Of the 178 infants with surgically confirmed or autopsy-confirmed NEC or SIP, seven (4%) had CMV in intestinal tissue. Most infants in the cohort (n = 143) had NEC, and six of these infants (4%) had CMV detected in their intestinal tissue. Four cases were confirmed by both PCR and IHC, and two were confirmed by PCR only.

Fewer infants had SIP during the study period (n = 35). The only case with CMV found in intestinal tissue was confirmed by PCR.

Sanchez and colleagues reported that when infants with CMV-associated NEC were compared with CMV-negative cases, they had lower median gestational age (24 weeks vs. 28 weeks; P = .02), birth weight (649 g vs. 1,121 g; P = .04) and platelet count (16,000/mm3 vs. 50,000/mm3; P = .018).

The researchers noted that no associations between CMV-associated NEC and breastfeeding, age at diagnosis, male sex, cholestasis or mortality were observed.

“It’s really unclear as to which infants with CMV infection should be treated with an antiviral, namely ganciclovir and valganciclovir,” Sanchez said. “Given the severity of NEC both acutely and long-term, infants who are found to be CMV-infected at the time that they develop NEC likely should be treated. However, it really is not known if it will impact the NEC course.”

Sanchez added that no recommendations exist for CMV testing among infants diagnosed with NEC. He said this study may not change recommendations, but it could encourage physicians to consider CMV as a contributing factor to the condition.

Ideally, all newborns should be screened for CMV infection, Sanchez said. CMV has been linked to hearing loss and other adverse neurodevelopmental outcomes among infants, but most infants are tested for infection only if they do not pass their newborn hearing screen.

“Such universal testing may assist in determining a causal relationship between CMV infection and NEC or SIP that could lead to therapeutic or preventive strategies. That certainly is our goal.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

Pablo Sanchez 2019
Pablo J. Sanchez

According to research published in The Journal of Pediatrics, during a recent 17-year period, 4% of infants with necrotizing enterocolitis, or NEC, or spontaneous intestinal perforation, or SIP, in one NICU had intestinal infection with cytomegalovirus.

“NEC is a devastating condition in preterm infants that is associated with substantial morbidity and even mortality,” Pablo J. Sanchez, MD, a pediatric neonatologist and infectious disease specialist at Nationwide Children’s Hospital, told Infectious Diseases in Children. “CMV is an increasingly recognized pathogen among infants in the NICU, and postnatally acquired CMV infection has been attributed to ingestion of CMV-containing maternal milk. Trying to understand the potential etiologies of NEC and SIP, and especially [their] possible association with CMV, is important for development of treatment or preventive strategies.”

Sanchez and colleagues conducted a retrospective cohort study in the NICU at Nationwide Children’s Hospital. All infants received diagnoses of NEC (at least Bell stage 2B) or SIP between 2000 and 2016. The researchers tested paraffin-embedded surgical or autopsy intestinal tissues for CMV using PCR and immunohistochemistry (IHC).

Of the 178 infants with surgically confirmed or autopsy-confirmed NEC or SIP, seven (4%) had CMV in intestinal tissue. Most infants in the cohort (n = 143) had NEC, and six of these infants (4%) had CMV detected in their intestinal tissue. Four cases were confirmed by both PCR and IHC, and two were confirmed by PCR only.

Fewer infants had SIP during the study period (n = 35). The only case with CMV found in intestinal tissue was confirmed by PCR.

Sanchez and colleagues reported that when infants with CMV-associated NEC were compared with CMV-negative cases, they had lower median gestational age (24 weeks vs. 28 weeks; P = .02), birth weight (649 g vs. 1,121 g; P = .04) and platelet count (16,000/mm3 vs. 50,000/mm3; P = .018).

The researchers noted that no associations between CMV-associated NEC and breastfeeding, age at diagnosis, male sex, cholestasis or mortality were observed.

“It’s really unclear as to which infants with CMV infection should be treated with an antiviral, namely ganciclovir and valganciclovir,” Sanchez said. “Given the severity of NEC both acutely and long-term, infants who are found to be CMV-infected at the time that they develop NEC likely should be treated. However, it really is not known if it will impact the NEC course.”

Sanchez added that no recommendations exist for CMV testing among infants diagnosed with NEC. He said this study may not change recommendations, but it could encourage physicians to consider CMV as a contributing factor to the condition.

Ideally, all newborns should be screened for CMV infection, Sanchez said. CMV has been linked to hearing loss and other adverse neurodevelopmental outcomes among infants, but most infants are tested for infection only if they do not pass their newborn hearing screen.

“Such universal testing may assist in determining a causal relationship between CMV infection and NEC or SIP that could lead to therapeutic or preventive strategies. That certainly is our goal.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.