Parental attitudes toward newborn screening for cystic fibrosis

An Assessment of Public Preferences for Newborn Screening Using Best-Worst Scaling

OBJECTIVE

To identify and quantify public preferences for attributes of newborn screening conditions.

STUDY DESIGN

We conducted an online national survey of the public (n = 502) to evaluate preferences for attributes of candidate newborn screening conditions. Respondents were presented with hypothetical condition profiles that were defined using 10 attributes with 2-6 levels per attribute. Participants indicated whether they would recommend screening for a condition and which condition attributes were most and least important when making this decision (best-worst scaling). Difference scores were calculated and stratified by condition recommendation (recommend or not recommend for screening). Regression analyses were used to evaluate the effect of attributes on choice to screen or not screen.

RESULTS

The number of babies diagnosed was important to those who would recommend newborn screening for a profile, and age at which the treatment would start was important to those who would not recommend newborn screening. Cost was considered to be a key attribute, and treatment effectiveness and impact of making the diagnosis through newborn screening were of low importance for both groups.

CONCLUSION

Public preferences identified through survey methods that provide an adequate baseline understanding of newborn screening can be used to inform newborn screening decisions.

Parent Experience With False-Positive Newborn Screening Results for Cystic Fibrosis

BACKGROUND

The risk of psychosocial harm in families of infants with false-positive (FP) newborn bloodspot screening (NBS) results for cystic fibrosis (CF) is a longstanding concern. Whether well designed retrieval and confirmatory testing systems can mitigate risks remains unknown.

METHODS

Using a mixed-methods cohort design, we obtained prospective self-report data from mothers of infants with FP CF NBS results 2 to 3 months after confirmatory testing at Ontario's largest follow-up center, and from a randomly selected control sample of mothers of screen negative infants from the same region. Mothers completed a questionnaire assessing experience and psychosocial response. A sample of mothers of FP infants completed qualitative interviews.

RESULTS

One hundred thirty-four mothers of FP infants (response rate, 55%) and 411 controls (response rate, 47%) completed questionnaires; 54 mothers of FP infants were interviewed. Selected psychosocial response measures did not detect psychosocial distress in newborns or 1 year later (P > .05). Mothers recalled distress during notification of the positive result and in the follow-up testing period related to fear of chronic illness, but valued the screening system of care in mitigating concerns.

CONCLUSIONS

Although immediate distress was reported among mothers of FP infants, selected psychometric tools did not detect these concerns. The NBS center from which mothers were recruited minimizes delay between notification and confirmatory testing and ensures trained professionals are communicating results and facilitating follow-up. These factors may explain the presence of minimal psychosocial burden. The screening system reflected herein may be a model for NBS programs working to minimize FP-related psychosocial harm.

Newborn screening for cystic fibrosis - The parent perspective

BACKGROUND

Newborn screening for CF started 01/2011 in Switzerland. We investigated the parents' opinions about the information received, their feelings, and overall approval of the screening.

METHODS

This is a prospective questionnaire survey of all parents of positively screened children. Parents were phoned by CF-centres and invited for diagnostic investigations. They completed a questionnaire after the visit to the CF-centre.

RESULTS

From 2011-2013, 246 families received the questionnaire and 138 (56%) replied. Of these 77 (60%) found the information received at birth satisfactory; 124 (91%) found the information provided in the CF-centre satisfactory. Most parents (n=98, 78%) felt troubled or anxious when the CF-centre called, 51 (38%) remained anxious after the visit. Most parents (n=122; 88%) were satisfied with the screening, 4 (3%) were not, and 12 (9%) were unsure.

CONCLUSIONS

The smooth organisation of the screening process, with personal information by a CF specialist and short delays between this information and the final diagnostic testing, might have contributed to reduce anxiety among parents. Most families were grateful that their child had been screened, and are happy with the process.

Parental support for newborn screening for cystic fibrosis

AIM

To describe the attitudes among parents towards including cystic fibrosis (CF) in the newborn screening programme and towards the potential knowledge of their own carrier status.

METHODS

A questionnaire with three to five response categories and an information leaflet was posted to 143 CF parents, 3 matched diabetes and 3 matched population parents, the response rate being 85%, 74% and 70%, respectively. Comparisons between groups were made with statistical tests for independent groups.

RESULTS

Eighty-six percent of CF, 70% of diabetes and 77% of population parents were in favour of newborn screening for CF, 47%, 45% and 50%, respectively, wished to know their CF carrier status. The parental attitude was independent of the age of the child, as well as delay of diagnosis and well-being of the CF child at the time of diagnosis. Sixty percent of the CF parents experienced the diagnosis as delayed.

CONCLUSION

Parents in Sweden support CF newborn screening. Half of the parents wanted to know their CF carrier status.

Psychological effects of false-positive results in cystic fibrosis newborn screening: a two-year follow-up

OBJECTIVE

To evaluate parental stress after a false-positive result at the time of the cystic fibrosis (CF) newborn screening (NBS), attributable to heterozygotism or persistent hypertrypsinemia.

STUDY DESIGN

A prospective study was conducted in 86 French families at 3, 12, and 24 months after NBS. A psychologist conducted interviews with a questionnaire, the Perceived Stress Scale, and the Vulnerable Child Scale.

RESULTS

Overall, 96.5% of parents said they had been anxious at the time of the sweat test. However, 86% felt entirely reassured 3 months after the test. The mean Perceived Stress Scale score did not differ from that observed in the French population. Mean Vulnerable Child Scale scores were high, associated with a low Parental Perception of Child Vulnerability. These results did not differ significantly at 1 and 2 years. In total, 86% to 100% of families no longer worried about CF. All parents stated that they would have the test performed again for another child.

CONCLUSIONS

CF NBS can lead to false-positive results, causing parental anxiety, which quickly decreases after a sweat test performed soon after the phone call.

Cost-effectiveness of population screening for alpha-1 antitrypsin deficiency: a decision analysis

The objective was to assess the cost-effectiveness of population screening for alpha-1 antitrypsin (AAT) deficiency. The design was a Markov-based decision analytic model. Hypothetical cohorts were analyzed from birth and followed over time until death using Monte Carlo simulation. The following strategies were compared: 1) screen all newborns, 2) screen all 10-year-old children, and 3) do not screen. Screenees found to have PI*ZZ AAT deficiency received the benefits of lower smoking rates and were offered augmentation therapy. In keeping with reported experience, most (96%) non-screened AAT deficient individuals remained undiagnosed and, therefore, missed these benefits. Under base conditions, screening all newborns cost nearly $422,000 per quality-adjusted life-year (QALY) gained; this estimate fell to $92,135 per QALY when the cost of screening was minimized to $6 in the model. Delaying screening until age 10 decreased the incremental cost-effectiveness ratio (ICER) to nearly $317,000. In sensitivity analysis, when the prevalence of PI*ZZ individuals increased from a baseline of 1.96 to 16 per 10,000, the ICER for newborn screening decreased below $100,000 per QALY. When the cost of screening and augmentation therapy were decreased simultaneously with increasing PI*ZZ prevalence, there were many scenarios in which the ICER decreased below $50,000. While population-based screening for AAT deficiency is not cost-effective under current conditions, cost-effectiveness criteria could be satisfied when case-finding in a high prevalence population is undertaken.

Changing their minds with time: a comparison of hypothetical and actual reproductive behaviors in parents of children with cystic fibrosis

OBJECTIVE

Newborn screening for cystic fibrosis, with appropriate counseling, enables carrier parents to be informed early about future reproductive choices. Previous studies have assessed attitudes toward reproductive decisions in a hypothetical pregnancy or have measured reproductive behaviors. We aimed to measure parent attitudes to reproductive technologies and to compare prospectively these attitudes with later reproductive behaviors.

METHODS

Parents of children who had cystic fibrosis and were aged 2 to 7 years were surveyed at baseline using a written questionnaire that explored attitudes to prenatal testing and termination of pregnancy in a hypothetical pregnancy. Parent knowledge and access to genetic counseling services also were assessed. Five years later, we compared attitudes with actual reproductive behaviors.

RESULTS

Fifty-six mothers participated at baseline, and 43 were resurveyed 5 years later. Parent knowledge of cystic fibrosis and genetics was very good. A total of 93% had met a genetic counselor at the time of diagnosis, and more than half had on at least 1 subsequent occasion. At baseline, 82% reported that they would be likely to have prenatal diagnosis in a subsequent pregnancy, and 56% reported that they would be likely to terminate an affected pregnancy. Twenty-seven mothers since had been pregnant, with prenatal diagnosis used in 33 of the 55 pregnancies. In 67%, the hypothetically reported behavior regarding use of prenatal testing was the same as their actual behavior. Five of the 33 tested pregnancies were affected; all ended in termination. Reproductive choices in relationship to the number of children wanted, together with attitudes toward prenatal diagnosis and termination of pregnancy, were dynamic over time, with decisions having changed in both directions.

CONCLUSIONS

This cohort of parents has actively used reproductive technologies since the birth of a child who has cystic fibrosis that was diagnosed by newborn screening. The dynamic aspect of reproductive choices highlights the importance of ongoing access to genetic counseling beyond the initial period of diagnosis and education, regardless of whether parents report that they expect to use reproductive technologies.

Expanded newborn screening for biochemical disorders: the effect of a false-positive result

BACKGROUND

Newborn screening programs now identify children with >30 biochemical genetic disorders. False-positive identifications may increase as disorders are added to screening panels. Concerns arise regarding the potential impact on parental stress, family relationships, and perceptions of the child's health.

METHODS

Parents of 173 infants with false-positive screening results for a biochemical genetic disorder in the expanded newborn screening panel were compared with parents of 67 children with normal screening results. Parents completed an interview that elicited information about demographic features, child and parental health, and understanding of newborn screening. Parents also completed the parenting stress index.

RESULTS

Parents in the false-positive group attained higher total scores on the PSI than did parents in the normal-screened group, scoring higher on the parent-child dysfunction subscale and the difficult child subscale. Only approximately one third of parents in the false-positive group reported knowing the correct reason for repeat screening. Mothers who reported knowing the correct reason for their child's repeat screening test experienced less total stress than did mothers who were misinformed, were not informed, or did not remember.

CONCLUSIONS

False-positive screening results may affect parental stress and the parent-child relationship. Improved communication with parents regarding the need for repeat screening tests may reduce the negative impact of false-positive results.

Pediatricians' attitudes toward expanding newborn screening

OBJECTIVE

Traditional population screening focuses on conditions for which early treatment prevents severe morbidity and mortality. The classic example in pediatrics is newborn screening for phenylketonuria, which began in the 1960s. In 1968, Wilson and Jungner delineated 10 criteria that would justify population screening. These criteria have been reaffirmed by many newborn screening task forces as the standard for adding conditions to newborn screening programs. Today, however, some newborn screening programs are expanding to include conditions that may not meet all of the traditional screening criteria. Little is known about pediatricians' attitudes toward expanding screening. We examine the attitudes of pediatricians and pediatric subspecialists toward screening for cystic fibrosis (CF), Duchenne muscular dystrophy (DMD), fragile X, and type 1 diabetes.

METHODS

A cross-sectional survey was conducted of 600 pediatricians, including those who are members of the section of genetics, endocrinology, pulmonology, and neurology of the American Academy of Pediatrics. For each condition, pediatricians were queried about (1) testing high-risk infants, (2) newborn screening, and (3) population screening or testing beyond the newborn period. Demographic data were also collected.

RESULTS

A total of 232 (43%) of 537 eligible pediatricians returned surveys. More than 75% support testing high-risk infants for all conditions except type 1 diabetes. CF was the only condition for which >50% supported newborn screening. Newborn screening was preferred over screening older infants for all conditions except fragile X. Subspecialty affiliation did not have a significant impact with respect to attitudes about testing high-risk children, newborn screening, or screening beyond infancy. We analyzed the data by the number of patients with the queried condition under the physician's care and by the number of affected family members. Neither aspect was significant. We also analyzed the data by gender, by year of residency graduation, and by geographic location. None of these factors revealed significant differences in responses. For each condition, 8% to 41% of physicians would personally choose to test their own infant. We found that physicians' opinion about what they would want for their own children correlated with their attitude about population newborn screening. Those who would personally choose testing of their own infants were highly likely to support newborn screening for CF (98%), DMD (94%), and fragile X (98%), but only 78% of those who would personally opt for newborn screening of type 1 diabetes would also endorse population-based screening. This was statistically significant for each condition. Those who would choose not to test their own infants were significantly less likely to support newborn screening of the general population. One third of those who did not want to test their own newborns for CF supported population screening, whereas only one fifth supported DMD and fragile X population screening. For type 1 diabetes, 98% of those who would not personally choose newborn testing did not want it offered as a population screening program.

CONCLUSIONS

Most physicians support diagnostic genetic testing of high-risk children but are less supportive of expanding newborn screening, particularly for conditions that do not meet the Wilson and Jungner criteria. Willingness to expand newborn screening does not correlate with professional characteristics but rather with personal interest in testing of their own children.

Psychosocial issues in newborn screening for cystic fibrosis

Newborn screening for cystic fibrosis remains controversial because there is still little agreement that prophylactic interventions provide substantial long-term benefits. In such situations, where there are some medical benefits and the costs are not prohibitive, it is important to consider the psychosocial implications of screening. This paper reviews the evidence on the psychosocial issues raised by newborn screening for cystic fibrosis, in particular the issues of parental attitudes to screening, the evidence from families with an affected infant, the evidence from families with a carrier infant and the lessons for service delivery.

Evidence for newborn screening for cystic fibrosis

Different strategies are available for studying the effectiveness of newborn screening for cystic fibrosis (CF). Although observational studies suggest clinical benefits, their results are difficult to interpret because of the potential for several methodological problems. Randomised studies show that age at time of diagnosis is an important factor in the nutritional status of pancreatically insufficient patients and that a delayed diagnosis increases the risk of malnutrition in childhood. Effects on lung disease are more controversial. Advantages other than better clinical outcome or survival may be obtained by the implementation of CF neonatal screening, mainly the opportunity for presymptomatic trials and treatments and more informed reproductive choices for parents and relatives. Disadvantages of neonatal screening for CF include the detection of heterozygotes and the discovery of mild forms of disease.

Newborn screening for cystic fibrosis

CF newborn screening benefits growth and prevents malnutrition in children with CF. Increasing evidence suggests long-term pulmonary benefits, but these data are still accumulating. With a standardized approach to clinical care for these pre-symptomatic patients, we should be able to ask questions about the optimal treatment strategy for therapies that are currently available, perhaps through randomized clinical trials in this group. For developing therapies, Massachusetts will have identified its CF patients before they have sustained significant malnutrition and lung injury, and it may be these patients who will benefit most from therapies still on the horizon.

Why screen for cystic fibrosis? A clinician's view

Cystic fibrosis (CF) is relatively common, serious, and causes progressive lung damage. Clinical diagnosis may be delayed until lung damage has occurred, and infection may start as early as six weeks of life. A well organised screening programme should identify the great majority of affected infants within the first three weeks after birth, which leaves a small time window during which effective preventive treatment and surveillance may be instituted. Active treatment, whether for screened or unscreened infants, improves clinical status and long-term survival of CF patients. It is anticipated that new treatments will become available within the next few years, and these will clearly give maximal benefit to young infants if instituted before lung damage is evident. In addition to any hypothetical effects on morbidity and survival, pre-symptomatic diagnosis greatly improves the doctor-parent relationship. Economic arguments may be distorted, but, at best, screening is cost-beneficial, and, at worst, it is cost-neutral. The overwhelming majority of CF professionals and parents universally support neonatal screening, so the onus is therefore on those who oppose screening to prove that their approach offers a superior strategy.

Maternal anxiety and attitudes to universal neonatal hearing screening

Neonatal hearing screening of all babies within the maternity unit is now feasible using transient evoked otoacoustic emission (TEOAE) recording. However, in many maternity units in the United Kingdom, the majority of babies are discharged within the first 48 hours. During the first two days of life, there is a higher proportion of babies in whom emissions cannot be recorded. A universal TEOAE hearing screen has been implemented in Whipps Cross Hospital. As 70% of the babies are discharged from the maternity unit before they are 48 hours old, a two stage screen was implemented, with failure at the initial TEOAE test being followed by a retest after 4-6 weeks. The maternal anxiety caused by this model was investigated in 288 mothers enrolled for the initial TEOAE test. Generally, anxiety was low and attitudes towards the screen were positive. Ninety-seven per cent of mothers considered the screen to be worthwhile at the initial test with 15% feeling it had caused some anxiety but less than 1% being very worried. The mothers who had some anxieties were not dissatisfied with the screen, and within this group there was no increase in the proportion of babies who had failed the initial test. At the retest, two of 57 mothers (3.5%) considered they were very worried, but there was no significant deterioration in attitude towards the screen. Spielberger's State-Trait Anxiety Inventory revealed no significant difference in the anxiety state of the retest group when compared with a control group whose babies had not received a neonatal hearing test. The results of the initial test and the retest did not influence the anxiety state of the mothers. Ways of minimizing anxiety caused to a minority of mothers whilst maintaining positive attitudes to the screen are discussed.