Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine.

I'm Melanie Cole, and joining me today is Dr. Christine Salvatore. She's the Chief of Pediatric Infectious Diseases in the Department of Pediatrics at Weill Cornell Medicine. And she's here to talk about screenings for CMV or cytomegalovirus. Welcome, Dr. Salvatore. I'm so glad you're here. Tell the listeners what CMV really is. How common is it? What are we seeing right now?

Christine Salvatore, MD: Yes. Thank you. Thank you so much, Melanie, for the introduction. CMV, or cytomegalovirus, it's a very common virus; however, nobody knows about it really. It's one of those herpes viruses. A lot of the population, everybody in general, knows what a herpes virus is, but does not know that there are so many kinds of different herpes viruses. The one that we know for sure is the so-called HSV, the one that gives you the cold sore, for example. But it's not the only herpes virus. Other herpes viruses are varicella, for example, the chickenpox and CMV. This is a virus like any other kind of a herpes virus that, once you get it, it's going to sleep in you forever, but really sleeps and doesn't really wake up unless there are particular conditions.

It's very, very frequent, as I mentioned, and we all get it. Usually, up to, I would say, 60% of the kids at six years of age, they are positive already, they came in contact with this virus. And when you reach your thirties, forties, probably around 80% of the population is already positive. So, that tells you how frequent this virus is.

Melanie Cole, MS: Wow. So as we think of CMV, and you just gave us some really incredible statistics, a lot of people have it. It sleeps, it's dormant, like maybe shingles or some of these other types of viruses, even C. diff. Some of these things, they sit dormant until they awaken. So, what are the signs and symptoms of it awakening of the infection actually being active?

Christine Salvatore, MD: The awakening, by itself, the virus can have different presentations, depending on when you get the infection, first of all, because it's different if you get it as I'm going to mention when you are still in the mom's womb or you are getting the infections once you're born already.

So, the other condition that we always have to think about is how is your immune system? Because that is extremely important, because the presentation of somebody who is healthy is completely different compared to somebody who, for example, could have his immune system that is not working very well. But let's see the common way, the normal healthy person, child, adult, that come across this virus for the first time can present in many ways. And I can tell you the majority, most likely, they have no idea, because it's so-called asymptomatic infection. That means you get it and you didn't know that you had it. It maybe didn't give you fever. It didn't give you any enlarged lymph nodes. It didn't give you really any signs and symptoms. Your body was able to defend itself without showing any kind of symptoms or signs.

In other ways, instead, you can have something that is like a mononucleosis. A lot of people know this term. And it's like flu-like symptoms. Like you see you have some muscle aches, we technically call it myalgia. You have some fevers, maybe you have some sore throat. These comes and goes on their own. You sometimes don't even test yourself. You say, "Okay, it's a virus," but maybe it was not one of those usual virus that think about like the flu, but maybe it was CMV.

In immunocompromised though, this can be a little bit more intense, because with immunocompromised, I'm just talking about maybe adults or children that have cancer. So, they are undergoing chemotherapy. So, their immune system is not working. In those cases, the body's not able really to defend themselves completely, at least. And so, the manifestations could be more severe. You can have pneumonia, you can have hepatitis, you can have the virus that is going around the blood, we call it viremia in that case, or it could be also sometimes even going to the brain, causing some encephalitis. So, there are very different ways of presenting. And of course, then there is the presentation of the babies. Like I mentioned, when they get the infection through the womb, but that is a different chapter. We can discuss it as well later.

Melanie Cole, MS: Yes. That's a whole different podcast. But now, I've heard there's a new universal screening. Can you speak about that?

Christine Salvatore, MD: That is something that a lot of the pediatric infectious diseases specialists have been asking for a long period of time. And the reason of this is because congenital infection. And congenital infection means when the babies get the infection, when they're not born yet, but they're still in mom's belly. And what CMV can cause is severe long-term outcomes. The majority of these babies are born fine, that you don't know that they have the infection. They're born with this infection, the majority of them, 90%. Ten percent of these babies instead will see it. There is something wrong probably at birth. They're small, they have a small head maybe, or they have a rash on their body. So, this prompts usually the doctors in the nurseries to say, "Hmm, there is something going on. Let's check for CMV," for example. But as mentioned, this is going to just pick up a very small percentage of babies. The majority of these babies are not being checked, because there is nothing really that shows up when they are born.

So, what are the consequences of this? The consequences could be hearing loss on the long term; could be learning disabilities, that could be associated with the hearing loss, but could be also independent from those. So, because we are missing these babies, we don't have the possibility to intervene if we need to.

So, we have asked for a long period of time why instead of doing only some sectorial screening, we start doing this the screening on everybody. And that's when two states in the United States, actually, are doing it. One is Minnesota, and the other one, actually, is New York State. New York State started in October of last year, screening every single baby that is born in the state. And they are doing that through the regular standard newborn screening that is being done by law on all babies. What they did, they just added a CMV PCR on the newborn screening. And this is actually picking up a lot of the babies that we would have missed otherwise. And as infectious diseases, we are really thrilled that we are able to help if there is the need or at least follow these babies in the long-term.

Melanie Cole, MS: That's excellent. And it seems like it's easier to implement than people think and all the red tape. And so, I hope more states implement this screening. Now, tell us about your clinic and your team and what you do for patients and families that attend the clinic.

Christine Salvatore, MD: So, when these babies are identified, they are referred to me. One things that I didn't mention is that there are 11 specialized centers in the state that have been identified by the Department of Health. We, as Weill Cornell, we are one of them. And our outreach is many of the hospitals in the upper Manhattan area, Queens, some part of the Bronx. When the DOH gets a positive screening, they send it to me. They call me and they say, "Look, this baby resulted positive."

So, what we do is we call the family to come to do, first of all, a confirmatory testing, because we always want to be sure that this is real. So, we do the urine, we call them, I talk with them. I counsel with them a lot because, of course, this is a very new thing. None, I have to tell you, none of my families have an idea what CMV is and they all ask, "Okay, what is it about?" So, I educate my parents when they come. First of all, I try to reassure them when they come for the first time. I tell them very clearly that, so far, when the testing is positive, usually it is positive indeed, and the baby has this infection. We go over what does it mean, a workup that needs to be done, because it's not done just doing the urine. We have to do a little bit more complex workup that will look at the brain, look at the liver, looks at the blood to say, "Okay, your baby is actually fine. We will just need to look at them on the long term," especially from a hearing perspective though, because that is something that I work very closely with the audiologists. And I refer all these babies for hearing. That is one of the things that can develop later at two years, three years, even at six years of life. It can develop sensorineural hearing loss. That means the nerve is not working very well. And so, they have to follow with the audiologist. If by any chance the workup is positive, then I tell them, "Look, we can try to prevent all this." There is a medicine that we can give to the baby. The baby may improve or may prevent having the learning disability, the hearing loss, but that is not being offered to all of them." It's hard for the parents at the first few visits, because of course, you never want to know a cute baby that come to my clinic to say, "Look. They have a congenital infection." But on the long term, they get reassured, they relax, but it's not easy at the beginning, definitely, and I understand them.

Melanie Cole, MS: And you're so compassionate, Dr. Salvatore. You are. And we can hear it when you're with those babies and the patients. I am sure that they feel it as well. I'd like you to wrap up with the summary, what you would like patients to take away from this informative episode about CMV, what it really means to families in the longterm and how you help them.

Christine Salvatore, MD: So, definitely, the most important thing is try to, especially if you're pregnant in general and you have toddlers at home, or you work with children like in a daycare center, I always say try to have the standard precautions that we would always try to have in general. Wash your hands very carefully. Try not to put a pacifier in your mouth to clean it. These are things that potentially can reduce a little bit the transmission of the virus, so it could reduce the chances of these babies to get an infection. It's not the only one, but definitely that is the first thing.

And second thing is many of these babies are going to be fine, so it's nothing to be worried about. But it's important though to do a workup, to have a better picture of what the baby has, so that we can help them on the long term to avoid all these possible long-term outcomes. What we need to do though is try to increase the awareness of the virus and think that it's still lucky, even though a legislation was passed that there should be an increase in the knowledge that we are transmitting to the parents that are expecting, but just to be relaxed, that we are there for them if they need to ask questions. Absolutely, they can always reach out. Just live a normal life because many of these babies will be fine.

One thing that probably I want to just to add is that there is a vaccine that is not approved yet. But definitely, it's the way that we are going and we are aiming to try actually to decrease the incidence of CMV on its own with a vaccine that hopefully in the next few years is going to be available for everybody.

Melanie Cole, MS: Thank you so much, Dr. Salvatore. This was so informative and educational. Thank you again for joining us. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcast and Google Podcast. And for more health tips, go to weillcornell.org and search podcasts. And don't forget to check out Back To Health. So many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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