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A total of 195 children were randomised to zidovudine (immediate) or matching placebo (deferred) in a multicentre double blind trial in vertically HIV infected children with early disease (the PENTA 1 trial). Median follow up in the blinded phase was 1.9 years. Thereafter, individual children were unblinded following the results of adult trials showing a benefit of combination antiretroviral therapy (ART) over monotherapy, but follow up continued and is reported here until December 1998 (total follow up 4.6 years). Median time to starting ART in the deferred group was 2.7 years; 19% of deferred children had not started ART by 1999. Throughout follow up, the percentage of time spent on no ART, monotherapy, dual, and triple ART was 21%, 44%, 29%, and 6% respectively for immediate and 62%, 12%, 18%, and 8% for deferred groups. During the blinded phase eight (7.8%) immediate and 12 (13.3%) deferred children developed AIDS or died (log rank p = 0.24); overall 21 immediate and 20 deferred children progressed. In an analysis including all children regardless of original allocation, the risk of progression to AIDS or death, adjusting for age and time since trial entry was significantly lower during 1997-98 (2.4 per 100 child years) than during 1992-96 (6.6 per 100 child years), most likely a result of increased use of combination ART.

In most cases (about 80%) the HIV-infection of children is acquired during pregnancy or birth. Therefore peculiarities for diagnostic procedures and in the natural course of the disease can be expected if compared to AIDS acquired at adult age. Further interesting questions are the frequency of the (vertical) transmission from the infected mother to the child, the influence of mother- and/or child-related factors as well as the method of delivery on this transmission frequency.In order to answer these questions the children of HIV-infected mothers since April 1, 1988 have been examined virologically, immunologically and clinically since birth by 6 study centers according to a standard protocol. The pregnancy data of the mothers have been documented, according to uniform criteria. Pre- or perinatally infected children not known to be antibody-positive at birth have been separately analysed.The frequency of pre/perinatal transmission from the mother to the child is 15.3%, the elective caesarean section seems to lower the transmission rate. Mother and/or infant related cofactors of the transmission could not be defined. In comparison to the control groups of the intrauterine HIV-exposed but not infected children, at birth the HIV-infected children were clinically and immunologically not ill. During their first months some of the infected children had a significant increase of serum IgG. Oral candidiasis, chronic recurrent diarrhoea and bacterial infections are indicator symptoms of beginning HIV-disease. The Minimum-AIDS-Prevalence in the child's first year is 24%. The relatively late AIDS manifestation (3.7 years) and the average value of 28 months of survival in retrospective observed children were a remarkable result.In general, the course of an HIV-infection in children of HIV-positive women in Germany seems to be comparable to results in other countries. The frequency of transmission from mother to child is relatively low (15.3%) and is an important result for maternity care. The caesarean section should be considered. The course of pregnancy must be examined more subtly in order to find out the still unclear causes of transmission. The Minimum-AIDS-Prevalence of 24% and the frequency of HIV-related signs and symptoms of 29% in the child's first year make it necessary to observe these children rather closely during this time.

S-fimbriated Escherichia coli, which cause sepsis and meningitis in the newbom, bind to sialic acid-containing glycoprotein structures on the surface of human buccal epithelial cells. The dependence of · this binding on host age was examined. S-fimbriated · E. coli adhered in comparable numbers to cells in newborns, infants, children and adults (23.0 ± 8.6; 23.1 ± 11.5; 24.7 ± 7.9; 28.9 ± 8.8). Thus, the increased susceptibility of neonates to infections caused by S-fimbriated E. coli cannot be explained by enhanced · adhesion to epithelial cells, Die S-Fimbrien vermittelte Adhiision von Escherichia coli an menschliche Mundschleimhautzellen ist altersunabhängig. S-Fimbrien tragende Escherichia coli, die Sepsis und Meningitis . im Neugeborenenalter verursachen, binden an sialinsäurehaltige Glycoproteine atif der Oberfläche menschlicher Mundschleimhautzellen. Wir untersuchten die Abhängigkeit · der Bindung vom Alter des Schleimhautzellenspenders. S-Fimbrien tragende. E. coli banden in vergleichbarer Zahl an Zellen von Neugeborenen, Säuglingen, älteren · Kindern und Erwachsenen (23,0 ± 8,6; 23,1 ± 11,5; 24,7 ± 7,9; 28,9 ± 8,8). Die vermehrte Empfänglichkeit von Neugeborenen für Infektionen, die durch S- Fimbrien tragende E. coli verursacht werden, kann nicht mit einer verstärkten Adhäsion an Mundschleimhautzellen erklärt wer.den.

We investigated the ability of meconium, feces from human milk-fed (HMF) newborns, and feces from formula-fed (FF) newborns to inhibit adhesion of S-fimbriated E. coli to human buccal epithelial cells. S-fimbriae are a common property of E.·coli strains causing sepsis and meningitis in neonates. Meconium had the highest content of neuraminic acid and the strongest inhibitory effect on bacterial adhesion. HMF also exerted high inhibitory activity while FF was markedly less active: To achieve inhibitory effects comparable to HMF a sixfold amount of FF was required. Glycoproteins from excretions were separated by gel chromatography. Fractions obtained were analyzed for adhesion-inhibiting activity. In all excretions analyzed, the mucin-containing fraction could be identified as the major inhibitory component. Inhibition was probably mediated by specific interaction of this fraction with S-fimbriae, as shown by binding of isolated fimbriae on Western blots after electrophoretic separation of glycoproteins. In conclusion, our data support the view that the mucin-containing fraction from meconium and human milk exerts antibacterial functions by preventing adhesin-mediated binding of pathogenic bacteria to mucosal epithelia. Key Words: S-fimbriated E. coli-Inhibition of adhesion-Meconium- Feces of human milk-fed newborns-Feces of formula-fed newborns-Mucins.

We investigated the presence of factors in human milkthat inhibit Invasion of pathogenic bacteria. The efl'ect of human milk fat globule membrane (HMFGM) components on adhesion of cloned S-fimbriated Escherichia coli to human buccal epithelial cells was analyzed. S fimbriae are a common feature of E. coli strains causing sepsis and meningitis in newborns and are bound to epithelia via sialyl-(a-2-3)galactoside structures. Human milk fat globules (HMFG) could be agglutinated by the above-mentioned bacteria. Agglutination could be inhibited by fetuin, human glycophorin, and a 1-acid glycoprotein. In addition, pretreatment of HMFG with Jlibrio cholerae neuraminidase markedly reduced bacterium-induced agglutinations, indicating the involvement of neuraminic acid-containing glycoproteins. In contrast, Iipid droplets of infant formula or artificiallipid emulsions (Intralipid) could not be agglutinated. HMFG were present in stools of breast-fed neonates as shown by indirect immunofluorescence staining with a monoclonal antibody directed against carbohydrate residues present on HMFGM. These HMFG could be agglutinated by bacteria. HMFG inhibited E. coli adhesion to buccal epithelial cells. To further characterize relevant E. coli binding structures, HMFGM components w~re separated by gel chromatography. The mucin fraction showed the most pronounced inhibitory efrect on adhesion of S-fimbriated E. coli to human buccal epithelial cells. Our data soggest that HMFG inhibit bacterial adhesion in the entire intestine and thereby may provide protection against bacterial infection.

In order ot improve and standardize medical and psychosocial care for infants born to HIV-positive mothers, a prospective multicenter study has been initiated at 6 university hospitals in West-Germany in 1987. Aims of the study are: 1) determination of the rate of vertical HIV-transmission, relevant maternal risk factors and the clinical symptomatology of pre-or perinatally acquired HIV-infections, 2) identification of immunological and virological laboratory markers important for the verification and staging of HIV-infections in infants, 3) elaboration of an interdisciplinary approach to the care of HIV-infected children and their families, integrating medical care, social and psychological attendance.

Introduction Treatment options for children with HIV-1 are limited. We aimed to compare activity and safety of three dualnucleoside analogue reverse-transcriptase inhibitor (NRTI) regimens with or without a protease inhibitor in previously untreated children with HIV-1. Methods In our multicentre trial, we randomly assigned 36 children to zidovudine and lamivudine, 45 to zidovudine and abacavir, and 47 to lamivudine and abacavir. Children who were symptomfree (n=55) were also randomly assigned to receive nelfinavir or placebo. Children with more advanced disease received open-label nelfinavir (73). Primary endpoints were change in plasma HIV-1 RNA at 24 and 48 weeks for the NRTI comparison and occurrence of serious adverse events for both randomised comparisons. Analyses were by intention to treat. Findings Children had a median CD4 percentage of 22% (IQR 15–29) and a mean HIV-1 RNA concentration of 5·0 log copies/mL (SD 0·8). One child was lost to follow-up and one died of sepsis. At 48 weeks, in the zidovudine/lamivudine, zidovudine/abacavir, and lamivudine/abacavir groups, mean HIV-1 RNA had decreased by 1·71, 2·19, and 2·63 log copies/mL, respectively (estimated in absence of nelfinavir) (p=0·02 after adjustment for baseline factors). One child had a hypersensitivity reaction to abacavir; and three with possible reactions stopped abacavir. There were 24 serious adverse events—six in the symptom-free children (all on nelfinavir), but none were attributed to nelfinavir. Interpretation Regimens containing abacavir were more effective than zidovudine/lamivudine. Such regimens could be combined with protease inhibitors and non-nucleoside reverse transcriptase inhibitors for safe and effective treatment of previously untreated children with HIV-1.