Questions&Answers- After the delivery - The Israeli Association for CMV Pregnancy

After the delivery:

The tests that confirm whether the baby has congenital CMV:

Saliva test – performed in some hospitals and provides a reliable answer only if negative, indicating that the fetus was not infected. Its advantage is the simplicity of sample collection.
A positive result, indicating infection, may also result from passage through the birth canal or breastfeeding, and therefore is not definitive. If the saliva test is positive, a urine test must also be performed.
Urine test – provides a reliable and definitive answer regarding whether the baby was infected during pregnancy. Results are usually available within a few days of sample collection. However, unlike the saliva test, there can sometimes be technical difficulty in collecting a urine sample from a newborn.

Urine test results:

Negative – indicates the baby was not infected. This concludes the story of a pregnancy with CMV, and there is no further concern about the virus. After birth, the baby is like any other infant, and postnatal infection is not expected to have long-term consequences.
Positive – indicates the baby was infected during pregnancy.

It is crucial to perform these tests within the first three weeks of life. After this period, it is generally not possible to determine with certainty whether the infection was intrauterine or occurred during birth or afterward.

Another option for diagnosing congenital CMV if the first three-week window was missed is the Guthrie paper test (routine newborn blood spot test collected in the first days of life). This method is limited and is only accurate if positive. A negative result on the Guthrie paper test does not rule out congenital CMV.

If the urine test is positive, several additional tests are performed after birth:

Blood tests – complete blood count and kidney and liver function.
Brain ultrasound – performed by a pediatric radiologist.
Eye exam – performed by an ophthalmologist to rule out findings consistent with congenital infection.
Bera hearing test (ABR) – evaluates the brainstem response to sound stimuli. More information on this test can be found in the Q&A tab.

Postnatal test results and follow-up

If all targeted scans during pregnancy were normal, both brain ultrasound and postnatal eye exams are expected to be normal.
There is still a risk of hearing problems, which cannot be detected through prenatal imaging.

Normal test results –
If postnatal tests are normal, the baby is defined as asymptomatic and is expected to have normal neurological development.

However, even an asymptomatic baby may develop hearing impairment in 5–7% of cases. Therefore, children infected with CMV in utero will continue follow-up with a pediatric infectious disease specialist and hearing monitoring during the first years of life. In most hospitals, follow-up is every six months until around age five.

In some hospitals, follow-up in the first year also includes neurology and ophthalmology. Differences in hospital follow-up protocols can be found in the “Protocols – Diagnosis, Treatment, and Follow-up” tab.

Abnormal test results –
If hearing impairment is detected, even if isolated without other signs of infection, the infectious disease specialist will recommend starting treatment with Valganciclovir, which has been shown to be highly effective in preventing further hearing deterioration and, in some cases, improving hearing affected by the virus.

In some cases, a brain ultrasound shows a finding called LSV. Previously, experts believed this indicated a risk of future hearing loss, and babies received medication to prevent deterioration. Today, improved imaging shows LSV occurs in a significant proportion of newborns, but follow-up has not shown increased rates of hearing loss. Therefore, in most cases, these babies do not receive medication.

Some hospitals follow the treatment protocol of Prof. David Kimberlin from the University of Birmingham, Alabama, a pioneer in congenital CMV treatment, which prescribes medication twice daily for six months.

Other hospitals follow the protocol developed from the work of Prof. Yaakov Amir, one of the first in the world to extend treatment through the baby’s first year, with twice daily dosing for the first three months and once daily for the next nine months.

More information about the medication can be found in the Q&A tab.

Beyond medication, rehabilitation intervention is important for children with hearing loss. According to the Israeli Ministry of Health guidelines on hearing assessment in infants and children, children should be referred for hearing rehabilitation by six months of age, preferably by three months. It is therefore advisable to request a referral to an organization or center specializing in hearing rehabilitation for infants and children with congenital CMV and hearing impairment.

The Bera / abr is a hearing test that checks the brain stem’s reaction to sound stimuli.

During the test, electrodes are attached to the baby’s head and a small earpiece is placed in the ear.

The test must be done during sleep, and therefore, until the baby can be independently put to sleep, the test will only be done during natural sleep. It is best to bring the baby to the test as tired as possible.

If the baby cannot be naturally put to sleep, a sleep inducing syrup will be used. The syrup is administered to the baby by a nurse who checks their vital signs, the child wakes up a few minutes after the test and needs to remain under parental observation at home on the day of the test.

It is important to note that the hearing screening test done to all newborns is not enough in case of suspected congenital CMV infection, and that is why the Bera/abr test is necessary as well.

The Ministry of Health recommends breastfeeding, and babies with CMV are no exception to this recommendation.

The baby’s infection with CMV after birth does not have a long-term effect such as the one possible with intrauterine infection, so that a mother who is infected with the virus does not need to be concerned about infecting the baby. On the contrary, as with any illness, it is better and advisable to breastfeed in order to pass on antibodies to the baby.

If the preterm baby is born with congenital CMV, the mother can breastfeed him with no restrictions, since he carries the antibodies from the time of the pregnancy and will not contract the virus due to breastfeeding.

If the preterm baby was not infected with the CMV virus during pregnancy, the recommendation is for maternal milk nutrition. However, it is known that small preterm babies can become infected with CMV from maternal milk and their condition might deteriorate due to the infection. These infections probably do not cause long-term damage, and therefore we try to reduce the quantity of the virus in the maternal milk by freezing the milk before feeding.

In any case, consult the preterm department staff before feeding, and it is recommended to consult an infectious diseases doctor specializing in the CMV virus

The CMV virus requires specific knowledge. Since this is the most common congenital virus in Israel and worldwide, it is widely investigated, and the frequency of the discoveries – followed by changes to the monitoring and treatment protocol – are of significance, so the specialist’s daily engagement with the subject is of great importance.

Therefore, it is important to be monitored by an infectious diseases doctor who is an expert on the subject and no settle for a general pediatrics infectious diseases doctor.

You can find the contact details under the tab Important Telephone Numbers.

If a hearing impairment is discovered, even if this is an isolated impairment without any other sign of infection, with the recommendation of the infectious disease specialist, the baby will start drug treatment with a drug called Valganciclovir, proven to be very effective in stopping the deterioration in hearing and in certain cases even in improving the hearing that was impaired due to the virus.

In some cases, the brain ultrasound finds a finding called LSV. In the past, experts thought that the finding suggests possible future hearing impairment, and those babies would receive drug treatment in the aim of preventing hearing deterioration. Nowadays, even though LSV is found in a high rate of newborns due to improvement in imaging measures, but their follow-up did not indicate any increase in the prevalence of hearing impairment. Therefore, in most cases, these babies will not receive drug treatment.

The drug Valganciclovir, or under the brand name Valcyte, is an anti-viral drug that greatly reduces the amount of CMV viruses in the patient’s body. The reduction in the number of viruses diminishes the inflammatory process caused by the virus. The drug has been used from the 80s of the previous century. The drug has one known side effect in human beings: Decrease in the number of neutrophils white blood cells, which necessitates follow-up on blood counts and in the event of a decrease, the temporary discontinuation of the drug. Most significant side effects, such as impairment of male fertility, were described in lab animals, but not in human beings.

Some of the hospitals in Israel treat with Valganciclovir according to the treatment protocol by Prof. David Kimberlin from Birmingham University in Alabama, the global pioneer of CMV drug treatment, that dictates that the drug needs to be received twice a day for six months.

Other hospitals follow the treatment protocol constructed following the multiannual work of Prof. Jacob Amir, who was among the first in the world to extend treatment with the drug to the first year of the baby’s life, at a dosage of twice a day for the first three months and once a day for additional nine months.

Under the tab Protocols – Diagnosis, Treatment and Follow-Up you can read about the protocols that were given to us from the different hospitals

In order to receive the drug, you need to receive approval from the HMO through a process called 29c, performed directly with the HMO, after receiving instruction and after the attending infectious diseases doctor fills out the forms.

Most children, up to the age of 4, are carriers of many diseases and viruses, among which the CMV virus as well, which they constantly excrete through their bodily fluids. Pregnant women, and other at-risk populations always need to be careful about coming into contact with the bodily fluids and excretions of young children, and CMV is no exception.

You can see here the Rules for Preventing Infection.

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