Contribution of Breastfeeding to False-Positive Saliva Polymerase Chain Reaction for Newborn Congenital Cytomegalovirus Screening.

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.

Racial and Ethnic Differences in the Prevalence of Congenital Cytomegalovirus Infection.

OBJECTIVE: To evaluate the impact of race and ethnicity upon the prevalence and clinical spectrum of congenital cytomegalovirus infection (cCMV). STUDY DESIGN: From 2007 to 2012, 100 332 infants from 7 medical centers were screened for cCMV while in the hospital. Ethnicity and race were collected and cCMV prevalence rates were calculated. RESULTS: The overall prevalence of cCMV in the cohort was 4.5 per 1000 live births (95% CI, 4.1-4.9). Black infants had the highest cCMV prevalence (9.5 per 1000 live births; 95% CI, 8.3-11.0), followed by multiracial infants (7.8 per 1000 live births; 95% CI, 4.7-12.0). Significantly lower prevalence rates were observed in non-Hispanic white infants (2.7 per 1000 live births; 95% CI, 2.2-3.3), Hispanic white infants (3.0 per 1000 live births; 95% CI, 2.4-3.6), and Asian infants (1.0 per 1000 live births; 95% CI, 0.3-2.5). After adjusting for socioeconomic status and maternal age, black infants were significantly more likely to have cCMV compared with non-Hispanic white infants (adjusted prevalence OR, 1.9; 95% CI, 1.4-2.5). Hispanic white infants had a slightly lower risk of having cCMV compared with non-Hispanic white infants (adjusted prevalence OR, 0.7; 95% CI, 0.5-1.0). However, no significant differences in symptomatic cCMV (9.6%) and sensorineural hearing loss (7.8%) were observed between the race/ethnic groups. CONCLUSIONS: Significant racial and ethnic differences exist in the prevalence of cCMV, even after adjusting for socioeconomic status and maternal age. Although once infected, the newborn disease and rates of hearing loss in infants are similar with respect to race and ethnicity.

Newborn Dried Blood Spot Polymerase Chain Reaction to Identify Infants with Congenital Cytomegalovirus-Associated Sensorineural Hearing Loss.

OBJECTIVE: To determine the utility of dried blood spot (DBS) polymerase chain reaction (PCR) in identifying infants with cytomegalovirus (CMV) infection-associated sensorineural hearing loss (SNHL). STUDY DESIGN: Newborns at 7 US hospitals between March 2007 and March 2012 were screened for CMV by saliva rapid culture and/or PCR. Infected infants were monitored for SNHL during the first 4 years of life to determine sensitivity, specificity, and positive and negative likelihood ratios of DBS PCR for identifying CMV-associated SNHL. RESULTS: DBS at birth was positive in 11 of 26 children (42%) with SNHL at age 4 years and in 72 of 270 children (27%) with normal hearing (P = .11). The sensitivity (42.3%; 95% CI, 23.4%-63.1%) and specificity (73.3%; 95% CI, 67.6%-78.5%) was low for DBS PCR in identifying children with SNHL at age 4 years. The positive and negative likelihood ratios of DBS PCR positivity to detect CMV-associated SNHL at age 4 years were 1.6 (95% CI, 0.97-2.6) and 0.8 (95% CI, 0.6-1.1), respectively. There was no difference in DBS viral loads between children with SNHL and those without SNHL. CONCLUSIONS: DBS PCR for CMV has low sensitivity and specificity for identifying infants with CMV-associated hearing loss. These findings, together with previous reports, demonstrate that DBS PCR does not identify either the majority of CMV-infected newborns or those with CMV-associated SNHL early in life.

Intravenous or enteral loop diuretics for preterm infants with (or developing) chronic lung disease.

BACKGROUND: Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES: To assess the risks and benefits of administration of a diuretic acting on the loop of Henle (loop diuretic) in preterm infants with or developing chronic lung disease (CLD). SEARCH STRATEGY: Standard search method of the Cochrane Neonatal Review Group was used. Initial search included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1974 to 1998). In addition, several abstract books of national and international American and European Societies were hand searched. The MEDLINE and the Cochrane Central searches were updated in March 2007 and December 2010.  The EMBASE search was completed in April 2007 and December 2010. Additional searches in CINAHL, clinicaltrials.gov and controlled-trials.com was completed in December 2010. SELECTION CRITERIA: Trials in which preterm infants with or developing chronic lung disease and at least five days of age were all randomly allocated to receive a loop diuretic either enterally or intravenously were included in this analysis. DATA COLLECTION AND ANALYSIS: The standard method for the Cochrane Collaboration described in the Cochrane Collaboration Handbook were used. Two investigators extracted, assessed and coded separately all data for each study. Parallel and cross-over trials were combined and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS: The only loop diuretic used in the six studies that met the selection criteria was furosemide. Most studies focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants < 3 weeks of age developing CLD, furosemide administration has either inconsistent effects or no detectable effect. In infants > 3 weeks of age with CLD, a single intravenous dose of 1 mg/kg of furosemide improves lung compliance and airway resistance for one hour. Chronic administration of furosemide improves both oxygenation and lung compliance. AUTHORS' CONCLUSIONS: In view of the lack of data from randomized trials concerning effects on important clinical outcomes, routine or sustained use of systemic loop diuretics in infants with (or developing) CLD cannot be recommended based on current evidence. Randomized trials are needed to assess the effects of furosemide administration on survival, duration of ventilatory support and oxygen administration, length of hospital stay, potential complications and long-term outcome.

Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease.

BACKGROUND: Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES: To assess the risks and benefits of diuretics acting on distal segments of the renal tubule (distal diuretics) in preterm infants with or developing chronic lung disease (CLD). SEARCH STRATEGY: The standard method of the Cochrane Neonatal Review Group were used. Initially, MEDLINE (1966 to November 2001), EMBASE (1974 to November 2001) and the Cochrane Controlled Trials Register (CENTRAL,The Cochrane Library, Issue 4, 2001) were searched. In addition, several abstract books of national and international American and European Societies were hand searched. Updated searches in April 2003, April 2007, and December 2010 did not yield any additional trials. SELECTION CRITERIA: Included in this analysis are trials in which preterm infants with or developing CLD and at least five days of age were randomly allocated to receive a diuretic acting on the distal renal tubule. Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. DATA COLLECTION AND ANALYSIS: The standard method for the Cochrane Collaboration described in the Cochrane Collaboration Handbook were used. Two investigators extracted, assessed and coded separately all data for each study. Any disagreement was resolved by discussion. Parallel and cross-over trials were combined. Whenever possible, baseline and final outcome data measured on a continuous scale was transformed into change scores using Follmann's formula. MAIN RESULTS: Of the six studies fulfilling entry criteria, most focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy.In preterm infants > 3 weeks of age with CLD, a four week treatment with thiazide and spironolactone improved lung compliance and reduced the need for furosemide. A single study showed thiazide and spironolactone decreased the risk of death and tended to decrease the risk for remaining intubated after eight weeks in infants who did not have access to corticosteroids, bronchodilators or aminophylline. AUTHORS' CONCLUSIONS: In preterm infants > 3 weeks of age with CLD, acute and chronic administration of distal diuretics improve pulmonary mechanics. However, positive effects should be interpreted with caution as the numbers of patients studied are small in surprisingly few randomized controlled trials.

Diuretics for respiratory distress syndrome in preterm infants.

BACKGROUND: Lung edema may complicate respiratory distress syndrome (RDS) in preterm infants. OBJECTIVES: The aim of this review was to assess the risks and benefits of diuretic administration in preterm infants with RDS. SEARCH METHODS: The standard search method of the Cochrane Neonatal Review Group was used. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE and EMBASE were searched. These searches were updated in April 2003, March 2007, January 2011. In addition, the abstract books of the American Thoracic Society and Society for Pediatric Research were searched. MEDLINE and CENTRAL search was conducted using the keyword "Respiratory Distress Syndrome" alone, to find studies of medications recently classified as diuretics, such as theophylline. In addition, EMBASE, controlled-trials.com and clinicaltrials.gov searches were completed in January 2011. MEDLINE search updated to August 2011. SELECTION CRITERIA: Trials were included in which preterm infants with RDS and less than five days of age were randomly allocated to diuretic administration. Of those trials, studies were only included in which at least one of the following outcomes measures was evaluated: mortality, patent ductus arteriosus, hypovolemic shock, intraventricular hemorrhage, renal failure, duration of oxygen supplementation, duration of mechanical ventilation, need for oxygen supplementation at 28 days of life, oxygen supplementation at 36 weeks of postmenstrual age (gestational age + postnatal age), length of stay, number of rehospitalizations during the first year of life, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS: The standard method for the Cochrane Collaboration, which is described in the Cochrane Collaboration Handbook, was used. Two investigators extracted, assessed and coded separately all data for each study. Any disagreement was resolved by discussion. MAIN RESULTS: Seven studies met inclusion criteria. Six studies using furosemide were done before the current era of prenatal steroids, surfactant and fluid restriction. Furosemide administration had no long-term benefits. Furosemide-induced transient improvement in pulmonary function did not outweigh an increased risk for patent ductus arteriosus and for hemodynamic instability. In one recent study, theophylline had no long-term benefits. Theophylline significantly decreased the risk of oligoanuria and transiently increased renal function, but did not significantly affect renal function at discharge or other outcomes. AUTHORS' CONCLUSIONS: There are no data to support routine administration of furosemide in preterm infants with RDS. Elective administration of furosemide to any patient with RDS should be carefully weighed against the risk of precipitating hypovolemia or developing a symptomatic patent ductus arteriosus. There are not enough data to support routine administration of low-dose theophylline in preterm infants with RDS.

Correlations of visual analog scales with Edinburgh Postnatal Depression Scale.

BACKGROUND: The purpose of this study was to search for correlations of scores on the visual analog scales (VAS) taken during the third week postpartum with scores on the Edinburgh Postnatal Depression Scale (EPDS) taken on approximately day 28 postpartum. METHODS: Thirty-four women filled out six visual analog scales on postpartum days 15-21 and took the EPDS at their 4-week postpartum visit to the clinic. Results were analyzed by simple linear regression and multiple backward stepwise regression. RESULTS: Responses to all six statements of the VAS correlated significantly with 4-week EPDS scores. Approximately 54% of the variability of 4-week EPDS scores can be predicted by the variability in VAS question 6. LIMITATIONS: Relatively small sample size is a moderately limiting factor of this study. CONCLUSION: Mood in the third week postpartum was predictive of EPDS score on postpartum day 28. Mood lability during the third week postpartum was a better predictor of EPDS score on day 28 than the other five measures, including feelings of sadness or anxiety. The EPDS may have potential use with an acceptable degree of accuracy earlier than the standard 4 weeks postpartum.

Urine Collection Method for the Diagnosis of Congenital Cytomegalovirus Infection.

Congenital cytomegalovirus infection is traditionally diagnosed by virus detection in saliva or urine. Virus culture was positive in significantly fewer urine samples collected using cotton balls in diapers (55.2%) than with samples collected by bags (93.2%) from newborns screened positive for CMV in saliva. However, polymerase chain reaction was positive in 95% of urine samples regardless of the collection method.

Postpartum thyroid measures and depressive symptomology: a pilot study.

CONTEXT: While correlations have been demonstrated between postpartum depression and psychosocial and circumstantial risk factors, some evidence exists for a similar relationship between postpartum depression and thyroid measures. OBJECTIVE: To search at 4 weeks postpartum for correlations of numerical scores on a postnatal depression screening tool and thyroid measures. METHODS: Subjects took the Edinburgh Postnatal Depression Scale (EPDS) prenatally and at 4 weeks postpartum. Participants were also given blood tests for thyroid-stimulating hormone (TSH), free thyroxine4, thyroid peroxidase, and thyroglobulin at the same testing intervals. RESULTS: Fifty-one subjects aged 18 years or older were recruited. Subjects with higher serum TSH at 4 weeks postpartum tended to have higher EPDS scores. Similarly, the 7 subjects (13.7%) with positive postnatal thyroid antibody tests were more likely than their counterparts to have higher EPDS scores. CONCLUSIONS: Presence of thyroid autoantibodies or higher TSH levels during the postpartum period may be related to depressive symptoms or dysphoric mood, even when clinical depression is not present. Either or both of these associations may contribute, along with other physiologic and psychosocial risk factors, to postpartum depression. (ClinicalTrials.gov number NCT00565032).

Ductus arteriosus aneurysm with community-acquired methicillin-resistant Staphylococcus aureus infection and spontaneous rupture: a potentially fatal quandary.

We present the case of a 6-month-old previously healthy girl who presented with high fever, labored breathing, and an enlarged cardiac silhouette on her chest radiograph. Comprehensive evaluation discovered a ductus arteriosus aneurysm and pericardial effusion with methicillin-resistant Staphylococcus aureus bacteremia. Despite pericardiocentesis and appropriate intravenous antibiotics, there was rapid enlargement of the aneurysm and accumulation of echogenic material within the ductus arteriosus aneurysm. Infected aneurysm rupture was identified during emergency surgery. This infant also had vocal cord paresis, a likely complication of the surgery. The clinical course, diagnosis, and treatment of this patient are discussed. Infection of a ductus arteriosus or an infected ductal arteriosus aneurysm is a rare and potentially fatal clinical entity. In the era of increasing community-acquired methicillin-resistant S aureus infections, this is a diagnosis that requires a high index of suspicion.