AMA Delegates Stop Short of Backing Universal Newborn Cytomegalovirus Screening

 by Cheryl Clark

A proposal to back universal newborn screening for congenital cytomegalovirus (CMV) was fiercely debated among the American Medical Association (AMA) House of Delegates on Tuesday.

The proposal was ultimately referred for more study after several speakers threw cold water on the idea, saying such policies -- now in place just in Minnesota and Connecticut -- could do more harm than good.

"This one's tough," said Eli Freiman, MD, a delegate from the Massachusetts Medical Society who spoke on the society's behalf. "I want us to screen for congenital CMV; I want us to do it right ... I'm asking us, as physicians, to understand the nuance and restraint that is required here."

"This does need to get done, but we're not there yet," he said.

In its rationale, the proposal said one in every 200 newborns in the U.S. has the congenital CMV infection, although most are asymptomatic at birth. It must be diagnosed within the first 21 days of life to distinguish it from postnatal CMV infections. And, it said, many infected individuals who are asymptomatic at birth develop late-onset hearing loss.

After Minnesota implemented universal CMV screening, the time of the child's first audiology visit dropped from 8.5 months of age to 25 days of age, and diagnoses rose from three to 61 per year, the proposal said.

In support, Pam Shaw, MD, of the American Academy of Pediatrics from Kansas City, who spoke as a pediatrician, said she saw an infant who passed their newborn screening but developed hearing loss at 18 months. "They were delayed in their speech and development," which a CMV screening policy would have caught and prevented, she said.

"Universal screening has significantly increased our ability to identify infants with or at risk for congenital CMV-associated hearing loss and neurological abnormalities," said Laurel Ries, MD, alternate Minnesota delegate.

But many of the delegates were reluctant to move forward without more studies.

"We're talking about screening nearly 4 million newborns per year to diagnose approximately 20,000 cases, 85% of which will not be symptomatic," and for whom treatment is not now recommended, said Dana Block-Abraham, DO, an alternate delegate from the American College of Obstetricians and Gynecologists who spoke on behalf of the college.

At the same time, she said, "a positive screening test could create substantial anxiety for families while they wait and see over the 27 months whether these sequelae develop. ... We don't know yet if this is best practice."

Freiman also was cautious without appropriate studies to show that universal screening reduces harm. He explained that in his state of Massachusetts, about 70,000 babies are born each year, and screening would mean that about 350 would be identified and 30 would be symptomatic, meaning they'd be already identified.

"But what do we do with the 200 plus infants that are asymptomatic or would never go on to develop severe disease? We don't know if identifying those infants is meaningful," he said. "We're asking for a legislative solution that could potentially worry 200 additional families, require 200 additional specialty follow-ups," and would require resources and time, when "we don't know if it's effective yet."

Joseph Sanfrancesco, MD, alternate delegate of the College of American Pathologists speaking on behalf of the Pathologist's Section Council, also said the proposed policy was premature. It would cause "a significant uptick in high complexity molecular confirmatory testing" when there's a shortage of laboratory professionals.

A study should investigate laboratories' ability to handle universal CMV testing in the many states that don't now have it, he urged.

https://www.medpagetoday.com/meetingcoverage/ama/121697