Running head: QUALITY IMPROVEMENT PROJECT 1

Quality Improvement Project: Postnatal Acquired Cytomegalovirus

Katie Bowling, RN

Bon Secours Memorial College of Nursing

Professor Tamarah Pearson, MSN, RN, CEN, CN IV

NUR 3207

July 22, 2017

Honor Code “I Pledge.”

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Quality Improvement Project: Postnatal Acquired Cytomegalovirus

Cytomegalovirus (CMV) is a widespread virus that infects individuals of any age (Center

for Disease Control and Prevention (CDC), 2016). According to the CDC (2016), one in three

children will contract the virus by age five years with half of adults being infected by 40 years of

age. CMV may lay dormant within a person’s body without showing signs or symptoms while

still having the ability to pass from one person to another. The virus can be spread in body fluids

from sexual contact, contact with urine or saliva, blood transfusions, during pregnancy from

mother to baby (congenital CMV), and through breast milk (CDC, 2016). Breast milk can be

contaminated with viral and bacterial pathogens (Pietrasanta, Ghirardi, Manca, Uccella, Gualdi,

Tota, Pugni, & Mosca, 2014). Individuals that are immunosuppressed are at greatest risk for

contracting CMV. Among the most vulnerable populations, preterm infants are at most risk for

contracting CMV. Breast milk has been shown to be the most beneficial by providing nutrition

and antibodies for infants, especially those born prematurely. On the other hand, the risk of

transmitting CMV from a CMV positive mother to a CMV negative infant is not without risk.

The practice in the Neonatal Intensive Care Unit (NICU) has been to test all mothers who

deliver infants at less than 32 weeks gestation for CMV. During the first week of the infant’s life,

while CMV results are pending, fresh breast milk is utilized. If the mother is CMV seropositive,

breast milk is frozen for no less than three days in order to decrease viral titers present in the

breast milk. Upon being frozen for three days, breast milk may be thawed and utilized for

feedings. In the instance that breast milk is needed for feedings and fresh breast milk is all that is

available, fresh breast milk is utilized. Also, in efforts to promote breastfeeding in the hospital

setting, breastfeeding is encouraged with little regard for the risk of transmitting CMV. The issue

at hand is the lack of evidence-based research distinctly proving that freezing the breast milk of a
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CMV positive mother as opposed to using fresh breast milk significantly reduces the risk of

transmitting CMV to the infant. Issues that also arise are educating mothers about the risks and

then contradicting the education by allowing the mother to use fresh breast milk and breastfeed

ultimately leads to confusion of nurses and mothers. With the lack of evidence supporting

freezing breast milk, best practices need to be utilized in order to improve the quality and safety

of care.

Postnatal CMV infections in preterm and very low birth weight (VLBW) infants can be

asymptomatic or present with CMV related sepsis-like syndrome (CMV-SLS). Serious

complications of postnatal CMV infections include hearing and vision loss, nutropenia, hepatitis,

and cholestasis (Jim, Chiu, Ho, Shu, Chang, Hung, Kao, Chang, Peng, Yui, & Chuu, 2015). In a

study conducted by Lanzieri et al., 2013, out of 299 infants fed untreated breast milk versus

frozen breast milk there was only a 6% decrease in acquired CMV infections and a 1% increase

in CMV-SLS for infants fed with frozen-thawed breast milk. In a study comparing freezing

breast milk to -20 degrees Celsius for three days and use of fresh breast milk, CMV transmission

rates were 2% higher in fresh breast milk (Omasdottir, Casper, Naver, Legnevall, Gustafsson,

Grillner, Zweygberg-Wirgart, Soderberg-Naucler, & Vanpee, 2015). The rate of acquiring CMV

or CMV-SLS from frozen breast milk is not significantly lower than fresh breast milk to warrant

testing postpartum mothers and freezing breast milk in order to decrease chances of acquiring

CMV. Transmission of CMV through breast milk is not uncommon but providing optimal

nutrition through fresh breast milk outweighs the risk (Jim et al., 2015).

The American Academy of Pediatrics released a statement in 2012 stating the value of

using fresh breast milk from CMV positive mothers is more beneficial than the risk of disease

related to CMV as there are no reports of long-term neurodevelopmental abnormalities (Lanzieri,

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Dollard, Josephson, Schmid, & Bialek, 2013). CMV infections are often unknown and do not

present with signs or symptoms. When following postnatal CMV infections through breast milk

routine screening for CMV is not recommended and long-term sequelae remains unknown (Alex,

2014). Long-term complications of extreme prematurity may include developmental delays,

cognitive and motor dysfunction but have no definitive research to support the link between

these delays and postnatal CMV infections. According to Jim et al. (2015), previous preterm

infants at corrected ages of 12 and 24 months who acquired postnatal CMV infections had no

adverse effects on outcomes, hearing, growth and neurodevelopment. More research is needed to

support alternative methods to significantly reduce the transmission of CMV through breast milk

without compromising the nutritious qualities.

As there is no outstanding evidence to support the policy of freezing the breast milk of all

CMV positive mothers that delivered an infant at less than 32 weeks, new guidelines should end

testing of postpartum mothers for CMV and freezing breast milk. Fresh breast milk should be

utilized and breast-feeding should be encouraged when possible. The focus should be on a

standard of care that optimizes nutrition and the beneficial antibodies received from fresh breast

milk. In return, this saves the hospital and patient money from testing, ensures evidence-based

research on the benefits of breast milk is followed and breast-feeding is encouraged. The

nutrition, lactation and infection control NICU committees, comprised of neonatologists,

nutritionists and nurses, should review the research before presenting the information to other

units involved. With these quality and safety standards in effect more efficient care is provided as

unnecessary testing and valuable breast milk is no longer frozen.

In order to implement this practice, all nurses and physicians should be educated on the

change in practice through email notifications, staff meetings and during daily huddle. The
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clinical care lead, nurse educator, nurse manager, and charge nurses should be unit champions of

the change in practice to educate, clarify questions and provide reinforcement for staff and the

medical team. Other units such as Labor and Delivery, Antepartum, Postpartum and lactation

staff should be educated on the changes as the physicians on these unit routinely order CMV

titers on mothers that deliver infant less than 32 weeks gestation. Laminated “fresh is best” cards

should be attached to breast milk freezers to serve as a visual reminder that fresh breast milk

should be utilized as the benefits exceed the risk. A dashboard, attached below, will be utilized to

track necessary data related to patients receiving breast milk. This tool will be utilized monthly

for all patients in the NICU. This tool will help identify infants most at risk and follow possible

complications. With the new evidence based practice in place there will be an undisputed quality

of care that focuses on optimizing nutrition, reducing patient cost and improving patient

outcomes for all preterm infants.

Medical Record # Gestational Weight Mother’s CMV Breast milk or Complications Eye exam Hearing
Age (Kg) status? Formula (s/s of CMV- results Loss
(known/unknown SLS)? (Left,
from maternal Right, or
pregnancy labs) Both)

References
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Alex, M. R. (2014). Congenital cytomegalovirus: Implications for maternal-child nursing.

American Journal of Maternal/Child Nursing 39(2), 122-129.

doi:10.1097/NMC.0000000000000008

Center for Disease Control and Prevention (CDC). (2016). Cytomegalovirus (CMV) and

congenital CMV infection. National Center for Immunization and Respiratory Diseases,

Division of Viral Diseases. Retrieved from https://www.cdc.gov/cmv/index.html

Jim, W., Chiu, N., Ho, C., Shu, C., Chang, J., Hung, Y., Kao, H., Chang, H. Peng, C., Yui, B.,

Chuu, C. (2015). Outcome of preterm infants with postnatal cytomegalovirus infection

via breast milk: A Two-year prospective follow-up study. Medicine, 94(43), 1835.

doi:10.1097/MD.0000000000001835

Lanzieri, T. M., Dollard, S. C., Josephson, C. D., Schmid, D. S., & Bialek, S. R. (2013). Breast

milk-acquired cytomegalovirus infection and disease in VLBW and premature infants.

Pediatrics, 131(6), 1937-1945. doi:10.1542/peds.2013-0076

Omasdottir, S., Casper, C., Naver, L., Legnevall, L., Gustafsson, F., Grillner, L., Zweygberg-

Wirgart, B., Soderberg-Naucler, C., & Vanpee, M. (2015). Cytomegalovirus infection and

neonatal outcome in extremely preterm infants after freezing of maternal milk. The

Pediatric Infectious Disease Journal, 34(5), 482-489.

doi:10.1097/INF.0000000000000619

Pietrasanta, C., Ghirardi, B., Manca, M. F., Uccella, S., Gualdi, C., Tota, E., Pugni, L., & Mosca,

F. (2014). Herpesviruses and breast milk. La Pediatria Medica e Chirurgica 36(3), 111-

115. doi: 10.4081/pmc.2014.5