{'fraction_non_alphanumeric': 0.027809307604994324, 'fraction_numerical': 0.018161180476730987, 'mean_word_length': 4.97457627118644, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 1, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Cytomegalovirus and transmission via breast milk: how to support breast milk to premature infants and prevent severe infection?

To the Editors: Recently, we published a review on transmission of human cytomegalovirus (HCMV) via breast milk to the premature infant. Studies revealed HCMV positivity of the infants of mothers being HCMV-IgG positive ranging from 5.7% to 58.6%, with symptomatic HCMV disease occurring in 0%–34.5% (median, 3.7%) and severe sepsis-like syndrome in 0%–13.8% (median, 0.7%). Evidence for long-term sequelae was scarce, suggesting only mild neurologic and cognitive impairment without hearing impairment. Recently, Hamele et al reported on severe morbidity and mortality associated with breast milk-acquired HCMV infection in 5 preterm infants of 24 ( 5) to 27 ( 1) weeks gestational age. These 5 cases add to a total of 18 infants that have been published since the early 1970s when human breast milk was known for the first time to be a potential source of HCMV infection. In 2 cases of these 18 infants, no details were provided, another 5 cases of 29 to 33 weeks gestational age did not experience severe disease as defined as sepsis-like syndrome, and the remaining 11 infants from 4 studies were reported to range from 23 to 28 weeks (23, 25, 24 – 28, and 24.4 0.5 weeks, respectively). Pasteurization constitutes the preferred procedure to inactivate HCMV in breast milk because freezing does not completely eliminate the virus. However, heating procedures significantly decrease protective factors contained in breast milk, which are fundamental for the advantages and possible long-term protection granted by breast-feeding. Despite the concerns over severe HCMV disease in a minority of very low birth weight infants, we would prefer an individual decision based on the health status of the preterm infant instead of a general approach by either pasteurization or withholding of breast milk. We believe that parents should be informed about the risk of HCMV acquisition of their preterm infant and the advantages of fresh milk feeding. Provided that informed consent is given and the preterm infant is in stable condition, fresh breast milk might be administered (Fig. 1). The suggested algorithm includes a careful risk-to-benefit evaluation of the infant’s current health status and the benefits of its own mother’s breast milk that might, in our opinion, clearly outweigh the risk of symptomatic HCMV infection. Weekly HCMV monitoring in the infant by polymerase chain reaction from urine samples is mandatory, and if the infant becomes positive, feeding fresh milk must be stopped to reduce viral loads in case of symptoms and signs of HCMV infection. Otherwise, feeding of fresh breast milk might be continued in infants of 28 weeks of gestational age. At a corrected age of 32 weeks, the physician could stop pasteurization or withholding of breast milk, based on the infant’s health status and a more mature immune system. We still share the view of Stagno et al that the low risk associated with the transmission of HCMV through breast milk is clearly outweighed by the well-established value of breast-feeding. Passive immunization with either HCMV monoclonal antibodies or immune globulins might be a case of debate for high risk low birth weight infants. Stefan Kurath, MD Bernhard Resch, MD Research Unit for Neonatal Infectious Diseases and Epidemiology Division of Neonatology Department of Paediatrics Medical University of Graz Graz, Austria bernhard.resch@medunigraz.at