758
Nutritional
HCV STATUS OF MOTHER AND INFANT
supplementation and mental development
p 382) that the the the effects of in prenatal and Bogota study’ supplementation postnatal period had a strong design, in that it was a randomised controlled trial. We concluded that it was probably the best study in this subjectHowever, even that study had drawbacks, in that there was no placebo, and all family members were fed, which may have affected their behaviour towards the children. (The Jamaican study also had this latter difficulty.) Additionally, the Griffiths test scores fluctuated erratically between sessions, which causes some concern about the validity of the test in that population. These children were in fact followed up after supplementation: their growth has been reportedand the school achievement data are being analysed. We were claiming that our study was the first to show that the development of children who were already stunted improved with supplementation. Of special interest was the fact that children over 3 years continued to improve. This suggests that we should re-evaluate the so-called vulnerable period of development. In one other study no improvement was found in undernourished children’s development (low weight-for-age) with supplementation alone.’ The only other study of which we are aware that looked at undernourished children was a pilot study that preceded the Bogota one.In that study there was a wide age range and no details of the test scores were reported. Neither study targeted stunted children. We agree that there is increasing evidence of the importance of nutrition for child development.
f
f
SiR,—Iagree with Professor Susser (Aug 10, on
Tropical Metabolism Research Unit, University of the West Indies, Mona, Kingston 7, Jamaica, WI
S. GRANTHAM-MCGREGOR S. WALKER C. POWELL
1. Waber DP, Vuori-Christiansen L, Ortiz N, et al. Nutritional supplementation, maternal education, and cognitive development of infants at risk of malnutrition. Am J Clin Nutr 1981; 34: 807-13. 2 Grantham-McGregor S. Field studies in early nutrition and later achievement. In Dobbmg J, ed. Early nutrition and later achievements. London: Academic Press, 1987: 128-74. 3. Super CM, Herrera MG, Mora JO. Long-term effects of food supplementation and psychosocial intervention on the physical growth of Colombian infants at risk of malnutrition. Child Devel 1990; 61: 29-49. 4. McKay H, Smisterra L, McKay A, Gomez H, Lloreda P Improving cognitive ability m chronically deprived children. Science 1978; 200: 270-78. 5. Mora JO, Amezquita A, Castro L, et al Nutrition, health and social factors related to intellectual performance World Rev Nutr Dietet 1974; 19: 205-36
Neonatal transmission of HCV from mother with chronic hepatitis SIR,-Dr Thaler and colleagues (July 6, p 17) describe vertical transmission of hepatitis C virus (HCV) in women at high risk of parenterally or sexually transmitted diseases, including HIV infection. We report a case of vertical transmission in which the mother had chronic non-A,non-B hepatitis due to blood transfusions, infection with hepatitis B virus and HIV being excluded. The diagnosis had been made by biopsy in this symptom-free woman with intermittently raised transaminases. Anti-HCV was detected by first and second generation ELISA (Ortho) during pregnancy and confirmed with the Chiron recombinant immunoblot assay (RIBA). She became pregnant in February, 1990; there were no medical problems during the pregnancy.
Polymerase chain reaction (PCR) amplification for HCV-RNA in serum was done by modified nested PCR with primers from the 5’ non-coding, highly conserved region of the HCV genome, followed by ethidium bromide staining and by hybridisation with an internal oligonucleotidic probe. Samples were tested at least twice, with normal serum samples extracted in parallel as negative controls.’ Transaminase activities, HCV status, and PCR findings are shown in the table. The baby was HCV-RNA negative at birth and positive at 4 months, showing evidence of recent, acute infection. The RIBA pattern showed that the baby acquired HCV antibodies that were not detectable in the mother; she was thus actively immunised against HCV. In contrast with previous observations (Thaler et al
and others 2-4) anti-HCV did not disappear, suggesting the onset of chronic disease. This might be related to the presence of chronic hepatitis in the mother. This observation demonstrates vertical transmission of HCV from a mother with anti-HCV positive chronic hepatitis. The possibility of transmission from high-risk mothers and our case of transmission from a mother with chronic active liver disease due to HCV underline the need to look for HCV by specific tests in all infants bom to HCV-positive mothers. Hepatology Service and INSERM U-24,
Hôpital Beaujon, 92118 Clichy, France, CTS, Versailles, and Institut Pasteur, Paris
F. DEGOS V. THIERS S. ERLINGER
J.
P. MAISONNEUVE L. NOEL C. BRÉCHOT P. BENHAMOU
1. Paterlini P, Gerken G, Nakajima E, et al. Polymerase chain reaction to detect hepatitis B virus DNA and RNA sequences m primary liver cancers from patients negative for hepatitis B surface antigen. N Engl Med 1990; 323: 80-85. J 2. Giovanninni M, Tagger A, Ribero ML, et al. Maternal-infant transmission of hepatitis C virus and HIV infections: a possible interaction. Lancet 1990, 335: 1166 3 Reesink HW, Wong VCW, Ip HMH, et al. Mother-to-infant transmission and hepatitis C virus Lancet 1990; 335: 1216-17. 4. Weintrub PS, Veereman G, Cowan MJ, Thaler MM. Vertical transmitted hepatitis C/HIV co-infection: a cause of infantile liver disease. Hepatology 1990; 12: 49
(abstr).
Cryoglobulinaemia and serological markers of hepatitis viruses StR,—Dr Durand (Feb 23, p 499) and Dr Casato (April 27, p 104) and their colleagues return to previous suggestions about the association between hepatotropic viruses and essential mixed cryoglobulinaemia (EMC). In particular, Casato et al support an association of both hepatitis C virus (HCV) and hepatitis B virus (HBV) with EMC. Levo et all first implicated HBV as a causative agent of EMCs. Subsequent studies have cast doubt on their findings.2-4 The differences among the various reports have been attributed mainly to case selection. The prevalence of HBV-related markers in a wide series of cryoglobulinaemias was examined retrospectively in a multicentre study, involving 23 clinical centres in eleven Italian regions. 596 patients with cryoglobulinaemia were divided into the following groups: 91 with associated connective tissue or lymphoproliferative diseases or with chronic infectious diseases (but not including chronic hepatitis); 81 with chronic liver diseases; 74 with liver involvement not clearly preceding onset of EMC (defmed as enlargement of the liver and a rise to at least twice the normal alanine aminotransferase and gamma glutamyltranspeptidase or serum alkaline phosphatase); and 350 without any liver involvement at
diagnosis. The cryoglobulins were characterised and the first measurements of HBV markers by radioimmunoassay or ELISA after diagnosis of cryoglobulinaemia were used in the analysis. The prevalence of HBV markers did not differ significantly in EMC and cryoglobulinaemias associated with conditions other than liver diseases (table). HBsAg and anti-HBc prevalences were higher than in EMC in cryoglobulinaemias secondary to chronic liver diseases (chi-squared test, p
Nutritional
HCV STATUS OF MOTHER AND INFANT
supplementation and mental development
p 382) that the the the effects of in prenatal and Bogota study’ supplementation postnatal period had a strong design, in that it was a randomised controlled trial. We concluded that it was probably the best study in this subjectHowever, even that study had drawbacks, in that there was no placebo, and all family members were fed, which may have affected their behaviour towards the children. (The Jamaican study also had this latter difficulty.) Additionally, the Griffiths test scores fluctuated erratically between sessions, which causes some concern about the validity of the test in that population. These children were in fact followed up after supplementation: their growth has been reportedand the school achievement data are being analysed. We were claiming that our study was the first to show that the development of children who were already stunted improved with supplementation. Of special interest was the fact that children over 3 years continued to improve. This suggests that we should re-evaluate the so-called vulnerable period of development. In one other study no improvement was found in undernourished children’s development (low weight-for-age) with supplementation alone.’ The only other study of which we are aware that looked at undernourished children was a pilot study that preceded the Bogota one.In that study there was a wide age range and no details of the test scores were reported. Neither study targeted stunted children. We agree that there is increasing evidence of the importance of nutrition for child development.
f
f
SiR,—Iagree with Professor Susser (Aug 10, on
Tropical Metabolism Research Unit, University of the West Indies, Mona, Kingston 7, Jamaica, WI
S. GRANTHAM-MCGREGOR S. WALKER C. POWELL
1. Waber DP, Vuori-Christiansen L, Ortiz N, et al. Nutritional supplementation, maternal education, and cognitive development of infants at risk of malnutrition. Am J Clin Nutr 1981; 34: 807-13. 2 Grantham-McGregor S. Field studies in early nutrition and later achievement. In Dobbmg J, ed. Early nutrition and later achievements. London: Academic Press, 1987: 128-74. 3. Super CM, Herrera MG, Mora JO. Long-term effects of food supplementation and psychosocial intervention on the physical growth of Colombian infants at risk of malnutrition. Child Devel 1990; 61: 29-49. 4. McKay H, Smisterra L, McKay A, Gomez H, Lloreda P Improving cognitive ability m chronically deprived children. Science 1978; 200: 270-78. 5. Mora JO, Amezquita A, Castro L, et al Nutrition, health and social factors related to intellectual performance World Rev Nutr Dietet 1974; 19: 205-36
Neonatal transmission of HCV from mother with chronic hepatitis SIR,-Dr Thaler and colleagues (July 6, p 17) describe vertical transmission of hepatitis C virus (HCV) in women at high risk of parenterally or sexually transmitted diseases, including HIV infection. We report a case of vertical transmission in which the mother had chronic non-A,non-B hepatitis due to blood transfusions, infection with hepatitis B virus and HIV being excluded. The diagnosis had been made by biopsy in this symptom-free woman with intermittently raised transaminases. Anti-HCV was detected by first and second generation ELISA (Ortho) during pregnancy and confirmed with the Chiron recombinant immunoblot assay (RIBA). She became pregnant in February, 1990; there were no medical problems during the pregnancy.
Polymerase chain reaction (PCR) amplification for HCV-RNA in serum was done by modified nested PCR with primers from the 5’ non-coding, highly conserved region of the HCV genome, followed by ethidium bromide staining and by hybridisation with an internal oligonucleotidic probe. Samples were tested at least twice, with normal serum samples extracted in parallel as negative controls.’ Transaminase activities, HCV status, and PCR findings are shown in the table. The baby was HCV-RNA negative at birth and positive at 4 months, showing evidence of recent, acute infection. The RIBA pattern showed that the baby acquired HCV antibodies that were not detectable in the mother; she was thus actively immunised against HCV. In contrast with previous observations (Thaler et al
and others 2-4) anti-HCV did not disappear, suggesting the onset of chronic disease. This might be related to the presence of chronic hepatitis in the mother. This observation demonstrates vertical transmission of HCV from a mother with anti-HCV positive chronic hepatitis. The possibility of transmission from high-risk mothers and our case of transmission from a mother with chronic active liver disease due to HCV underline the need to look for HCV by specific tests in all infants bom to HCV-positive mothers. Hepatology Service and INSERM U-24,
Hôpital Beaujon, 92118 Clichy, France, CTS, Versailles, and Institut Pasteur, Paris
F. DEGOS V. THIERS S. ERLINGER
J.
P. MAISONNEUVE L. NOEL C. BRÉCHOT P. BENHAMOU
1. Paterlini P, Gerken G, Nakajima E, et al. Polymerase chain reaction to detect hepatitis B virus DNA and RNA sequences m primary liver cancers from patients negative for hepatitis B surface antigen. N Engl Med 1990; 323: 80-85. J 2. Giovanninni M, Tagger A, Ribero ML, et al. Maternal-infant transmission of hepatitis C virus and HIV infections: a possible interaction. Lancet 1990, 335: 1166 3 Reesink HW, Wong VCW, Ip HMH, et al. Mother-to-infant transmission and hepatitis C virus Lancet 1990; 335: 1216-17. 4. Weintrub PS, Veereman G, Cowan MJ, Thaler MM. Vertical transmitted hepatitis C/HIV co-infection: a cause of infantile liver disease. Hepatology 1990; 12: 49
(abstr).
Cryoglobulinaemia and serological markers of hepatitis viruses StR,—Dr Durand (Feb 23, p 499) and Dr Casato (April 27, p 104) and their colleagues return to previous suggestions about the association between hepatotropic viruses and essential mixed cryoglobulinaemia (EMC). In particular, Casato et al support an association of both hepatitis C virus (HCV) and hepatitis B virus (HBV) with EMC. Levo et all first implicated HBV as a causative agent of EMCs. Subsequent studies have cast doubt on their findings.2-4 The differences among the various reports have been attributed mainly to case selection. The prevalence of HBV-related markers in a wide series of cryoglobulinaemias was examined retrospectively in a multicentre study, involving 23 clinical centres in eleven Italian regions. 596 patients with cryoglobulinaemia were divided into the following groups: 91 with associated connective tissue or lymphoproliferative diseases or with chronic infectious diseases (but not including chronic hepatitis); 81 with chronic liver diseases; 74 with liver involvement not clearly preceding onset of EMC (defmed as enlargement of the liver and a rise to at least twice the normal alanine aminotransferase and gamma glutamyltranspeptidase or serum alkaline phosphatase); and 350 without any liver involvement at
diagnosis. The cryoglobulins were characterised and the first measurements of HBV markers by radioimmunoassay or ELISA after diagnosis of cryoglobulinaemia were used in the analysis. The prevalence of HBV markers did not differ significantly in EMC and cryoglobulinaemias associated with conditions other than liver diseases (table). HBsAg and anti-HBc prevalences were higher than in EMC in cryoglobulinaemias secondary to chronic liver diseases (chi-squared test, p
