This Month in
THE JOURNAL OF
PEDIATRICS June 2009 • Volume 154 • Number 6
THE EDITORS’ PERSPECTIVES
CMV transmission in human milk
Clinicians are encouraging women to provide milk for
their preterm infants. A well-known risk is that fresh human
milk can transmit CMV to the newborn. However, the risks are
poorly defined. There are strategies to limit transmission, such as
freezing or pasteurizing the milk prior to feeding the infant.
However, such manipulations change the properties of the milk
and may limit its benefits. Capretti et al report a careful virology
study quantifying transmission of CMV from their mothers’
fresh milk to preterm infants. For a population of 80 infants, 32%
were fed CMV culture positive milk and 11% of the infants
became CMV positive with the same genotype that was cultured
from the milk. Of the 9 preterm infants infected with CMV, 3
had a mild sepsis-like illness and 5 others had mild neutropenia
and hyperbilirubinemia. Some of the infants were treated empir-
ically with IVIG, which may have limited transmission or symp-
toms, although this use of IVIG has not been validated. The
infants were doing well at 2 years, and the authors conclude that
CMV transmission from human milk causes a mild and self-
limited disease. However, severe cases of CMV pneumonia can
occur, and the small number of cases identified in this series is
inadequate to establish risk. It remains to be determined if the
possible benefits of feeding preterm infants fresh CMV positive
milk is worth the probable risks to some infants.
—Alan H. Jobe, MD, PhD
page 842
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Delayed diagnosis in common variable
immunodeficiency
A retrospective analysis of the clinical presentations of 32
children with primary common variable immunodeficiency is
published in this issue of The Journal. Urschel et al at the Ludwig
Maximillians University showed that the clinical presentations
were typically with respiratory tract infections, sinusitis, otitis
media, gastroenteritis, meningitis, sepsis, or pyelonephritis. Po-
liomyelitis occurred in two patients following vaccination. In
spite of these symptoms, there was a mean time between their
onset and the commencement of effective immunoglobulin re-
placement therapy of 5.8 years. The delay in diagnosis was
thought by the authors to be a reflection of the nonspecific
symptoms, and they emphasize the importance of being aware of
this disorder.
—Robert W. Wilmott, MD
Page 888
Bagging the bag
Studies showing the unreliability of bag specimens for
making the diagnosis of UTI are plentiful, yet the practice does
not seem to die. The current issue of The Journal contains yet
another such study, albeit with an interesting twist.
Etoubleau et al in France were able to examine the results
of culture of urine from 192 children in whom samples were
obtained from both bag and catheter specimens. Not surpris-
ingly, 7.5% of positive cultures obtained from bag specimens
were false positive. Intriguingly, 29% of negative cultures of bag
specimens were false negatives. The authors speculate on the
latter result, suggesting the antimicrobial cleansing regimen
which was employed. In any case, in this study, 40% of bag urine
specimens yielded either on incorrect or an impossible diagnosis.
—Thomas R. Welch, MD
Page 803
June 2009 A1