AAP urges broader testing for congenital CMV

Clinical takeaway: Consider congenital CMV testing in any newborn who fails initial hearing screening or has clinical findings linked to CMV, including thrombocytopenia, elevated liver enzymes, microcephaly, growth restriction, hepatosplenomegaly, or abnormal CNS imaging. Early identification can determine eligibility for valganciclovir treatment and long-term hearing surveillance.

The American Academy of Pediatrics (AAP) is recommending a more aggressive approach to identifying congenital cytomegalovirus (cCMV), the leading cause of nongenetic sensorineural hearing loss in children. In a new clinical report, AAP endorses a “hearing-targeted plus expanded testing” strategy designed to detect more infants with cCMV while stopping short of recommending universal newborn screening.

The report notes that only 10% to 15% of infants with cCMV show recognizable signs of disease at birth, leaving many cases undiagnosed during the narrow 21-day window in which congenital infection can be confirmed. The authors conclude that combining testing of infants who fail newborn hearing screening with testing of those who have CMV-associated risk factors or clinical findings offers the best evidence-based approach currently available.

Under the new recommendations, newborns should be tested for cCMV if there is maternal CMV infection during pregnancy, maternal HIV infection, failure of newborn hearing screening, abnormal CNS imaging, unexplained hepatosplenomegaly or petechial rash, elevated liver enzymes or conjugated bilirubin, thrombocytopenia, small-for-gestational-age birth weight, or microcephaly. AAP also advises considering routine testing of many preterm infants because they often cannot complete hearing screening within the first 21 days of life.

The report emphasizes that urine PCR remains the diagnostic gold standard. Saliva PCR is an acceptable screening test in term and late-preterm infants, but positive saliva results should be confirmed with urine testing obtained by 21 days of age.

Treatment recommendations were also updated. AAP recommends oral valganciclovir 32 mg/kg/day in 2 divided doses for 6 months in infants with moderate-to-severe cCMV disease, with therapy initiated as early as possible and no later than 13 weeks after birth. For infants with isolated sensorineural hearing loss, a 6-week course of valganciclovir may be offered on a case-by-case basis after consultation with a pediatric infectious disease specialist. Antiviral therapy is not recommended for infants with cCMV infection who have normal hearing and no evidence of disease.

“On the basis of the data reviewed, the AAP recommends an HT plus expanded testing program as the best evidence-based approach currently available for identifying cCMV in newborn infants,” the authors wrote.

What’s changed

• Recommends hearing-targeted plus expanded testing as the preferred newborn screening approach for cCMV.
• Provides specific criteria for expanded testing beyond failed hearing screens, including laboratory, imaging, and growth-related findings.
• Recommends valganciclovir treatment for all infants with moderate-to-severe cCMV disease when started within 13 weeks after birth.
• States that valganciclovir may be offered to infants with isolated sensorineural hearing loss, reflecting emerging evidence of potential hearing benefit.
• Introduces updated terminology, replacing “symptomatic” and “asymptomatic” cCMV with more specific categories including “cCMV disease,” “cCMV infection,” and “cCMV with isolated sensorineural hearing loss.”

Source: Tesini BL, et al. (2026 Sep 21) Pediatrics. Care of the Infant With Congenital Cytomegalovirus Infection: Clinical Report