The Pediatric Infectious Disease Journal  •  Volume 35, Number 3, March 2016
Colonization of Catheters
extraluminal colonization, whereas sonication and slicing mainly
detect intraluminal colonization. Studies recommending roll-plate
for the diagnosis of colonization were performed in adults with
central venous catheters.5,6,12 However, neonates are a specific pop-
ulation with a higher risk of infection because of age, placement
of catheters of different materials and sizes, and frequent catheter
manipulation.13 These factors could account for our poor findings
with the roll-plate technique.
Of the techniques used to detect intraluminal colonization,
catheter slicing before culture was better than sonication, as dem-
onstrated previously by our group.8 However, the findings of both
our previous and the present study were limited by the fact that the
procedure of catheter slicing is risky for healthcare workers if a
scalpel is used for the procedure.
Another limitation of the present study was that we did
not randomly distribute the order in which the techniques were
performed, as demonstrated in a previous study in our institution
showing that the likelihood of detection with several techniques
decreased progressively depending on the order in which the
techniques were performed.5 Even so, performing sonication and
slicing after roll-plate would have favored roll-plate, which was
not the case in the present study. Besides, despite silicone cath-
eters did not have clear distinct parts, we always used the catheter
tip for the roll-plate method, which may bias the results. Regard-
ing the coagulase-negative staphylococci isolates, as we did not
use molecular typing, the concordance between strains isolated
from the tip and from the blood may not be genetically the same.
We conclude that the roll-plate technique can be omit-
ted from the diagnosis of colonization of SN-PICCs at the cost
of missing confirmation of catheter origin in 4.8% of cases. We
recommend that future updates of guidelines for the diagnosis of
catheter-related infections should take our findings into account.
Recommendations for the diagnosis of catheter colonization cannot
be extrapolated to all kinds of catheters.
ACKNOWLEDGMENTS
The authors thank Thomas O’Boyle for his help in the prepa-
ration of the manuscript.
REFERENCES
1. Chitnis AS, Magill SS, Edwards JR, et al. Trends in Candida central line-
associated bloodstream infections among NICUs, 1999-2009. Pediatrics.
2012;130:e46–e52.
2. Milstone AM, Reich NG, Advani S, et al. Catheter dwell time and
CLABSIs in neonates with PICCs: a multicenter cohort study. Pediatrics.
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3. Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method
for identifying intravenous-catheter-related infection. N Engl J Med.
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4. Sherertz RJ, Raad II, Belani A, et al. Three-year experience with sonicated
vascular catheter cultures in a clinical microbiology laboratory. J Clin
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parative study of 3 different methods for the diagnosis of intravascular cath-
eter colonization. Clin Infect Dis. 2005;40:1096–1100.
6. Erb S, Frei R, Schregenberger K, et al. Sonication for diagnosis of cathe-
ter-related infection is not better than traditional roll-plate culture: a pro-
spective cohort study with 975 central venous catheters. Clin Infect Dis.
2014;59:541–544.
7. Sherertz RJ, Heard SO, Raad II. Diagnosis of triple-lumen catheter infec-
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J Clin Microbiol. 1997;35:641–646.
8. Martín-Rabadán P, Nisa HS, Guembe M, Bouza E. Neonatal percutane-
ously inserted silicone catheters must be sectioned to detect its colonization.
European Congress of Clinical Microbiology and Infectious Diseases, Oral
Sesion; May 10–13, 2014; Barcelona.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
9. Sannoh S, Clones B, Munoz J, et al. A multimodal approach to central
venous catheter hub care can decrease catheter-related bloodstream infec-
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11. Cercenado E, Ena J, Rodríguez-Créixems M, et al. A conservative pro-
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12. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diag-
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by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:1–45.
13. López Sastre JL, Fernández Colomer B, Coto Cotallo GD, et al. [Prospective
evaluation of percutaneous central venous catheters in newborn infants.
Castrillo Hospital Group]. An Esp Pediatr. 2000;53:138–147.
PROLONGED BREASTFEEDING IS ASSOCIATED
WITH LOWER RISK OF SEVERE HAND, FOOT AND
MOUTH DISEASE IN CHINESE CHILDREN
Yaping Li, MD,* Huiling Deng, MD,*† Mei Li, MD,*
Wenjun Wang, MD,* Xiaoli Jia, MD, PhD,* Ning Gao, MD,*
and Shuangsuo Dang, MD, PhD*
Abstract: To assess whether breastfeeding duration can affect risk of severe
hand, foot and mouth disease (HFMD) later in childhood, we retrospectively
analyzed demographic, environmental and breastfeeding data on 603 chil-
dren with severe HFMD and 1036 children with mild HFMD. Multivariate
analysis showed that breastfeeding for 6–12 months significantly reduced
the risk of severe HFMD, as did breastfeeding for >12 months.
Key Words: hand, foot and mouth disease, breastfeeding, duration, severity.
Accepted for publication September 30, 2015.
From the *Department of Infectious Diseases, Second Affiliated Hospital of
the Medical School of Xi’an Jiaotong University, Xi’an, Shaanxi, China;
and †Department of Infectious Diseases, Xi’an Children’s Hospital, Xi’an,
Shaanxi, China.
The authors declare no conflicts of interest and no external sources of funding.
Address for correspondence: Shuangsuo Dang, MD, PhD, Department of Infec-
tious Diseases, Second Affiliated Hospital of the Medical School of Xi’an
­Jiaotong University, No. 157, Xiwu Road, Xi’an, Shaanxi 710004, China.
E-mail: dang212@126.com.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.pidj.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/INF.0000000000001001
H and, foot and mouth disease (HFMD) is a common acute pediat-
ric infectious disease characterized by benign febrile exanthema
and typical vesicular rashes on the palms, soles, buttocks or in the
mouth.1 Usually, HFMD is mild and self-limiting, resolving in fewer
than 7 days. In rare cases, however, it becomes severe and leads to
critical complications, such as encephalomyelitis, brainstem encepha-
litis, aseptic meningitis, acute pulmonary edema and circulatory fail-
ure.2 Because no vaccine is yet available against the virological agents
linked to HFMD,3 controlling HFMD occurrence and progression is
essential, in particular by identifying patients more likely to develop
critical complications. Breastfeeding seems to protect against gas-
troenteritis, respiratory infection, sudden infant death syndrome and
other problems later in life,4–7 as well as against infection by HFMD-
associated enteroviruses during infancy.8 Our initial research sug-
gested that breastfeeding may also reduce the severity of HFMD later
in childhood.9 Here, we expanded on that work using a substantially
larger sample and assessing risk based on breastfeeding duration.
www.pidj.com | 353
Li et al The Pediatric Infectious Disease Journal  •  Volume 35, Number 3, March 2016
FIGURE 1.  Trend in risk of severe HFMD with different dura-
tions of breastfeeding.
METHODS
Patients
This study was approved by the Medical Ethics Commit-
tee of the Second Affiliated Hospital of the Medical College of
Xi’an Jiaotong University, Xi’an, China. Between April 2011 and
October 2014, clinical samples were randomly collected from all
children with HFMD admitted to the Second Affiliated Hospital or
to Xi’an Children’s Hospital, also in Xi’an, China. Children were
excluded from the study (n = 120) if their medical records did not
indicate duration of breastfeeding. In the end, 1639 pediatric in-
patients were retrospectively enrolled, comprising 603 with severe
HFMD and 1036 with mild HFMD. Of the 1639 patients, 318 were
analyzed in previous work from our group.9
HFMD was diagnosed based on criteria in the Hand, Foot
and Mouth Disease Clinical Guide (2010 edition) issued by the
Ministry of Health of the People’s Republic of China.10 Signs and
symptoms in most diagnosed cases occurred during epidemics in
preschool children, and they included typical exanthema on the
hands, feet, mouth and/or buttocks, with or without fever. HFMD
diagnosis was usually confirmed based on one of the following:
(1) a positive test for RNA from Coxsackievirus A16 (CoxA16),
Enterovirus 71 (EV71) or other enteroviruses; (2) isolation and
identification of CoxA16, EV71 or other enteroviruses linked to
HFMD or (3) a >4-fold increase in serum titer of antibodies against
CoxA16, EV71 or other enteroviruses linked to HFMD, based on
sampling during the acute and convalescent stages of the disease.10
Data Collection
Two authors (L.Y. and D.H.) used standardized forms to
extract data independently from medical records. Demographic
data were collected on the child’s gender, age, birth weight, resi-
dence, number of children in the family, feeding history, breast-
feeding duration, delivery mode, gestational age and birth season.
Data on clinical manifestations of HFMD were collected
to classify the patient as having mild or severe disease. Additional
354  |  www.pidj.com
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laboratory data included white blood cell count, fasting glucose
level and virus infection.
Patient Classification
Patients were classified as having mild or severe HFMD
using the criteria described in our previous work.9 Children with
severe HFMD were treated as “cases,” whereas those with mild
disease served as “controls” and were used as the reference group
when calculating odds ratios (ORs) describing the association of
different characteristics with severe disease.
Patients were also classified according to breastfeeding
duration as (1) never breastfed or breastfed for (2) ≤6 months,
(3) 6–12 months or (4) >12 months. Children who had never been
breastfed served as the reference group when calculating ORs of
severe HFMD associated with different breastfeeding durations.
Statistical Analyses
Data for continuous variables were summarized as mean ±
standard deviation or median (range), and intergroup differences
were assessed for significance using Student’s t test or the Wilcoxon
rank-sum test. Data for categorical variables were summarized as
numbers and percentages, and the χ2 test was used to assess dif-
ferences between patients with mild and severe HFMD. Univari-
ate and multivariate logistic regressions were used to identify risk
factors associated with severe HFMD based on ORs. All variables
with a univariate P value <0.20 along with those deemed to be
clinically significant were considered for inclusion in multivariate
models. All statistical analyses were performed using SPSS 13.0
(IBM, Chicago, IL). The threshold of significance for all statistical
tests was P < 0.05.
RESULTS
Comparison of Demographic and Clinical
Characteristics Between Patients with Mild and
Severe HFMD
Demographic and clinical characteristics of the 1639 chil-
dren with HFMD are compared in Table, Supplemental Digital
Content 1, http://links.lww.com/INF/C342. Patients with mild or
severe HFMD differed significantly in birth weight, residence,
feeding history, duration of breastfeeding and type of delivery.
Patients with severe disease were significantly worse than those
with mild disease in terms of presence and duration of fever, peak
temperature, cough, expectoration, central nervous system symp-
toms, white blood cell count, fasting glucose level, current EV71
infection, concomitant infection with Epstein–Barr virus, respira-
tory adenovirus, influenza virus and mycoplasma (data not shown).
Association Between Breastfeeding Duration and
HFMD Severity
Univariate analysis identified 3 ranges of breastfeed-
ing duration as significantly associated with reduced risk of
severe HFMD: ≤6 months [OR: 0.743; 95% confidence interval
(CI): 0.567–0.972], 6–12 months (OR: 0.678; 95% CI:
0.528–0.872) and >12 months (OR: 0.482; 95% CI: 0.330–0.703).
Multivariate logistic regression, which was carried out
after controlling for age, gender, birth weight, number of chil-
dren, delivery method and residence, showed that breastfeeding for
≤6 months was not associated with risk of severe HFMD (OR: 0.914;
95% CI: 0.793–1.053). In contrast, breastfeeding for 6–12 months
remained independently associated with risk of severe HFMD (OR:
0.701; 95% CI: 0.539–0.913), as did breastfeeding for >12 months
(OR: 0.504; 95% CI: 0.341–0.746; both P < 0.01). Figure 1
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Pediatric Infectious Disease Journal  •  Volume 35, Number 3, March 2016 Breastfeeding and HFMD
summarizes the trend in risk of severe HFMD for different dura-
tions of breastfeeding.
DISCUSSION
In this study with a relatively large sample stratified by dura-
tion of breastfeeding, we observed a significant positive association
between duration and risk of severe HFMD: longer breastfeeding
was associated with lower risk of severe disease. The results sug-
gest that 6 months is the minimum duration that protects against
severe disease. This provides support for the World Health Organi-
zation’s recommendation that mothers feed babies exclusively by
breastfeeding during the first 6 months,11 but it suggests the need
for even longer breastfeeding to ensure a protective effect against
severe HFMD.
Our findings confirm previous reports of an association
between duration of breastfeeding and aspects of HFMD onset
and clinical manifestations. A recent prospective cohort study
suggested that exclusively breastfeeding protects children against
occurrence of HFMD during the first 28 months.12 Another retro-
spective study suggested that breastfeeding reduces the risk of fever
in patients with HFMD.7
Our finding that breastfeeding for at least 6 months signifi-
cantly reduces risk of severe HFMD adds to the demonstrated ben-
efits of longer term breastfeeding against other diseases. A large
randomized trial showed that breastfeeding for >6 months reduced
risk of gastrointestinal infection.6 Lamberti et al4 showed that breast-
feeding for 6–23 months reduced morbidity and mortality caused by
diarrhea, whereas other work has reported that longer breastfeeding
reduced risk of respiratory infection-related diseases13 and type 2 dia-
betes.14 Our finding that only breastfeeding for longer than 6 months
exerted a protective effect may reflect the fact that infant immune
function during the first 24 months relies heavily on factors from the
mother, which do not persist for long in the baby’s circulation. Thus,
continued breastfeeding is needed to replenish these immune factors
until the infant’s own immune system begins to function effectively
on its own. Given that maternity leave in China and several other
countries is less than 6 months, at which point many mothers stop
breastfeeding for various reasons, we advocate targeted campaigns
to highlight the advantages of breastfeeding for more than 6 months.
How breastfeeding reduces risk of severe HFMD is unclear.
It may be related to the ability of breastfeeding to provide immune
protection against infection and reduce production of proinflamma-
tory factors in infants.15
Because this study focused on severe HFMD, we compared
children with severe disease with those with mild disease. This allowed
us to generate risk estimates specifically reflecting the likelihood of
severe disease, which is associated with potentially life-threatening
complications, thereby minimizing confounding by factors associated
only with mild HFMD, which is not linked to serious complications.
This study has several limitations. First, selection bias may be
an issue because all participants were in-patients and we excluded
those with incomplete medical records. Nevertheless, the fact that we
selected our participants randomly may counterbalance these biases.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Second, some data were based on parents’ recall, including the key
variable of breastfeeding duration. This introduces the risk of recall
bias, although the fact that we treated duration as a categorical rather
than continuous variable likely minimized the impact of this bias.
In addition, such bias would probably be comparable between the
patient subgroups with mild or severe HFMD, because the research-
ers collecting the data and interviewing parents were unaware a priori
of a link between breastfeeding duration and disease severity.
ACKNOWLEDGMENTS
We thank the physicians in the infectious disease depart-
ments at the Second Affiliated Hospital of the Medical College of
Xi’an Jiaotong University and at Xi’an Children’s Hospital for
their dedicated assistance with data collection.
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