Newborn and childhood screening programmes: criteria, evidence, and current policy

Social-emotional problems among three-year-olds differ based on the child's gender and custody arrangement

AIM

The aim of this study was to investigate mental health with respect to social-emotional problems among three-year-olds in relation to their gender, custody arrangements and place of residence.

METHODS

A cross-sectional population-based design was used, encompassing 7179 three-year-olds in northern Sweden during the period 2014-2017 from the regional Salut Register. Descriptive and comparative analyses were performed based on parents' responses on the Ages and Stages Questionnaires: Social-Emotional, supplemented with items on gender, custody arrangement and place of residence.

RESULTS

Parental-reported social-emotional problems were found in almost 10% of the children. Boys were reported to have more problems (12.3%) than girls (5.6%; p < 0.001). Parents were most concerned about children's eating habits and interactions at mealtimes. Parents not living together reported more problems among their children than those living together (p < 0.001). When stratifying by custody arrangement, girls in rural areas living alternately with each parent had more problems compared to those in urban areas (p < 0.008).

CONCLUSION

Gender and custody arrangements appear to be important factors for social-emotional problems among three-year-olds. Thus, such conditions should receive attention during preschool age, preferably by a systematic preventive strategy within Child Health Care.

Screening for galactosemia: is there a place for it?

Galactose is a hexose essential for production of energy, which has a prebiotic role and is essential for galactosylation of endogenous and exogenous proteins, ceramides, myelin sheath metabolism and others. The inability to metabolize galactose results in galactosemia. Galactosemia is an autosomal recessive disorder that affects newborns who are born asymptomatic, apparently well and healthy, then develop serious morbidity and mortality upon consuming milk that contains galactose. Those with galactosemia have a deficiency of an enzyme: classic galactosemia (type 1) results from severe deficiency of galactose-1-uridylyltransferase, while galactosemia type II results from galactokinase deficiency and type III results from galactose epimerase deficiency. Many countries include neonatal screening for galactosemia in their national newborn screening program; however, others do not, as the condition is rather rare, with an incidence of 1:30,000-1:100,000, and screening may be seen as not cost-effective and logistically demanding. Early detection and intervention by restricting galactose is not curative but is very rewarding, as it prevents deaths, mental retardation, liver cell failure, renal tubular acidosis and neurological sequelae, and may lead to resolution of cataract formation. Hence, national newborn screening for galactosemia prevents serious potential life-long suffering, morbidity and mortality. Recent advances in communication and biotechnology promise facilitation of logistics of neonatal screening, including improved cost-effectiveness.

Policy Making in Newborn Screening Needs a Structured and Transparent Approach

PURPOSE

Newborn bloodspot screening (NBS) programs have expanded significantly in the past years and are expected to expand further with the emergence of genetic technologies. Historically, NBS expansion has often occurred following ad hoc consideration of conditions, instead of a structured and transparent approach. In this review, we explore issues pertinent to NBS policy making, through the lens of the policy cycle: (a) agenda setting, (b) policy advice, (c) policy decision, (d) implementation, and (e) evaluation.

METHODS

A literature search was conducted to gather information on the elements specific to NBS and its policy making process.

RESULTS

The review highlighted two approaches to nominate a condition: a structured approach through horizon scanning; and an ad hoc process. For assessment of a condition, there was unanimous support for a robust process based on criteria. While the need to assess harms and benefits was a repeated theme in the articles, there is no agreed-upon threshold for benefit in decision-making. Furthermore, the literature was consistent in its recommendation for an overarching, independent, multidisciplinary group providing recommendations to government. An implementation plan focusing on the different levels on which NBS operates and the information needed on each level is essential for successful implementation. Continuously monitoring, and improving a program is vital, particularly following the implementation of screening for a new condition. An advisory committee could advise on implementation, development, review, modification, and cessation of (parts of) NBS.

CONCLUSION

The results highlight that there are a wave of issues facing NBS programs that policy makers must take into account when developing policy processes. What conditions to screen, and the technologies used in NBS, are both up for debate.

International differences in the evaluation of conditions for newborn bloodspot screening: a review of scientific literature and policy documents

Despite international adoption of newborn bloodspot screening (DBS), no two countries' screening programs are the same. This article aims to understand what factors influence DBS decision-making criteria and how conditions are assessed against them. In doing so, it offers unique insights into the international landscape of DBS. A systematic review on DBS criteria in scientific literature was first undertaken. Through this, five topics were identified for consideration when analyzing DBS decision-making. Using these five topics as a template, a side-by-side comparison was conducted on DBS in policy documents of eight countries. Programs are using different approaches to explore the same policy issues, including: the beneficiary of DBS, definition of criteria, the way conditions are assessed, level of evidence required, and recommendations after assessment. These differences have the potential to result in increased disparity across DBS internationally. Ultimately, governments need to decide on their role and develop an approach to DBS decision-making in line with this role. The analyses presented in this article highlight that despite programs' commonalities, no one 'DBS decision-making solution' exists. Understanding the different approaches to decision-making within the literature and policy settings, provides an objective starting point for structured decision-making approaches for DBS programs.

Current screening recommendations for developmental dysplasia of the hip may lead to an increase in open reduction

Most centres in the United Kingdom adopt a selective screening programme for developmental dysplasia of the hip (DDH) based on repeated clinical examination and selective ultrasound examination. The Newborn Infant Physical Examination protocol implemented in 2008 recommends a first examination at birth and then a second and final examination at six to ten weeks of age. Due to concerns over an increase in late presentations we performed a retrospective review of our 15-year results to establish if late presentation increases treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. The implementation of an opportunistic examination at three to five months could help to reduce the unintended consequences of the Newborn Infant Physical Examination programme.

The use of X-ray at 5 months in a selective screening programme for developmental dysplasia of the hip

BACKGROUND

The methods used for any screening programme for developmental dysplasia of the hip (DDH) can be controversial. This was an opportunistic audit of our selective ultrasound screening programme using an X-ray at 5 months to prevent inappropriate discharge due to the learning curve of ultrasound.

METHODS

Between 1990 and 2004 in Nottingham, UK, out of a total population of 108,500 births, approximately 11,500 neonates were screened using ultrasound. Any child with an ultrasound scan showing Graf α-angles greater than 60° (Graf Type I) with the hip in joint were discharged from the clinic. All of those discharged were subsequently X-rayed at 5 months in order to cover the learning curve of ultrasound. The X-rays were reviewed by a consultant radiologist and referred back to orthopaedics if there was lateralisation of the femoral head or an acetabular index above 30°.

RESULTS

Of approximately 11,000 X-rays performed, only 53 patients were referred back to orthopaedics, of which 47 had a complete data set. Of these 47 children, only 8 (17%) required intervention. On review of the original ultrasounds, Graf's α-angle did not seem to correlate well with the need for intervention, as all were Type I hips. The femoral head cover (FHC) appeared to be more predictive of the need for treatment. There have been no late presentations to our unit of DDH following a normal 5-month X-ray.

CONCLUSIONS

We now check the Graf α-angle, FHC and dynamic stability in the ultrasound assessment and only perform X-ray at 5 months if there was a low α-angle or low FHC. Since this change, there have been no late presentations of DDH from the population screened by ultrasound.

Diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale in India

BACKGROUND

Since there is no established measure for autism in India, we evaluated the diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale (CARS).

METHODS

Children and adolescents suspected of having autism were identified from the unit's database. Scale and item level scores of CARS were collected and analyzed. Sensitivity, specificity, likelihood ratios and predictive values for various CARS cut-off scores were calculated. Test-retest reliability and inter-rater reliability of CARS were examined. The dichotomized CARS score was correlated with the ICD-10 clinical diagnosis of autism to establish the criterion validity of CARS as a measure of autism. Convergent and divergent validity was calculated. The factor structure of CARS was demonstrated by principal components analysis.

RESULTS

A CARS score of > or =33 (sensitivity = 81.4%, specificity = 78.6%; area under the curve = 81%) was suggested for diagnostic use in Indian populations. The inter-rater reliability (ICC=0.74) and test-retest reliability (ICC=0.81) for CARS were good. Besides the adequate face and content validity, CARS demonstrated good internal consistency (Cronbach's alpha=0.79) and item-total correlation. There was moderate convergent validity with Binet-Kamat Test of Intelligence or Gessell's Developmental Schedule (r=0.42; P=0.01), divergent validity (r=-0.18; P=0.4) with ADD-H Comprehensive Teacher Rating Scale, and high concordance rate with the reference standard, ICD-10 diagnosis (82.52%; Cohen's kappa=0.40, P=0.001) in classifying autism. A 5-factor structure explained 65.34% of variance.

CONCLUSION

The CARS has strong psychometric properties and is now available for clinical and research work in India.

Provincial prenatal record revision: a multiple case study of evidence-based decision-making at the population-policy level

BACKGROUND

There is a significant gap in the knowledge translation literature related to how research evidence actually contributes to health care decision-making. Decisions around what care to provide at the population (rather than individual) level are particularly complex, involving considerations such as feasibility, cost, and population needs in addition to scientific evidence. One example of decision-making at this "population-policy" level involves what screening questions and intervention guides to include on standardized provincial prenatal records. As mandatory medical reporting forms, prenatal records are potentially powerful vehicles for promoting population-wide evidence-based care. However, the extent to which Canadian prenatal records reflect best-practice recommendations for the assessment of well-known risk factors such as maternal smoking and alcohol consumption varies markedly across Canadian provinces and territories. The goal of this study is to better understand the interaction of contextual factors and research evidence on decision-making at the population-policy level, by examining the processes by which provincial prenatal records are reviewed and revised.

METHODS

Guided by Dobrow et al.'s (2004) conceptual model for context-based evidence-based decision-making, this study will use a multiple case study design with embedded units of analysis to examine contextual factors influencing the prenatal record revision process in different Canadian provinces and territories. Data will be collected using multiple methods to construct detailed case descriptions for each province/territory. Using qualitative data analysis techniques, decision-making processes involving prenatal record content specifically related to maternal smoking and alcohol use will be compared both within and across each case, to identify key contextual factors influencing the uptake and application of research evidence by prenatal record review committees. All study participants will be required to give written informed consent prior to participating in data collection.

CONCLUSION

This study will advance knowledge in the field of evidence-based decision-making by illustrating the complex interaction of contextual factors and evidence on health policy decision-making by provincial-level committees. By increasing the transparency of decision-making within provincial prenatal record committees, this study will help inform more effective strategies for enhancing the integration of best-practice evidence into prenatal records.

Newborn blood spot screening in four countries: stakeholder involvement

While newborn blood spot screening has historically been viewed as a public health success, the potential harms and benefits are more finely balanced for new conditions being considered for program expansion. We highlight complex issues that must be addressed in policy decisions, which in turn requires a consideration of many stakeholder perspectives. Using national policy documents from the United Kingdom, the United States, Australia, and Canada, we describe the participation of stakeholder organizations in the newborn screening policy process, how such organizations have incorporated stakeholder views into their own policy writing, and their recommendations for inclusiveness. Stakeholder participation in newborn screening decision-making is widely acknowledged as important, and many methods have been endorsed - consultation as well as direct or indirect input into policy development. Differences across organizations and jurisdictions raise questions about the most effective approaches for facilitating inclusiveness, suggesting a need for formal evaluative research.

Duchenne muscular dystrophy: issues in expanding newborn screening

PURPOSE OF REVIEW

To illustrate potential risks and benefits of disease screening for newborns using the example of Duchenne muscular dystrophy.

RECENT FINDINGS

There is a wide range in the reported positive predictive value for screening male newborns for Duchenne muscular dystrophy by the creatine kinase level on dried blood spots. Some parental anxiety is associated with both early detection and false-positive screening results. No data are available about the impact of the diagnosis on the child, including the impact of early initiation of therapy. Studies suggest that few parents change their future reproductive planning based on identification of Duchenne muscular dystrophy through screening. Few data are available regarding the cost of newborn screening for Duchenne muscular dystrophy, and there are insufficient data to evaluate the cost-effectiveness of Duchenne muscular dystrophy screening.

SUMMARY

Available data are insufficient to recommend routine newborn screening for Duchenne muscular dystrophy. Understanding the gaps in knowledge provides insight into the evidence needed to recommend newborn screening for Duchenne muscular dystrophy. Studies are needed to evaluate the potential risks and benefits of screening, including the associated incremental costs.

Developmental dysplasia of the hip

In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations, have been established for more than 40 years but their effectiveness remains controversial. Whereas systematic sonographic imaging of newborn and young infants has afforded insights into normal and abnormal hip development in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution to premature degenerative hip disorders in adult life, and the benefits and harms of newborn screening. High quality studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip disease are needed, as are randomised trials to assess the effectiveness and safety of neonatal screening and early treatment.

Weight monitoring of breastfed babies in the United Kingdom--interpreting, explaining and intervening

Weighing infants in their first 6 months is an important aspect of growth monitoring and a common activity of child health care services worldwide. During the same 6 months, support for establishing breastfeeding and the promotion of continued exclusive breastfeeding are important activities of health professionals. Parents and health professionals may perceive conflicts between achieving both robust growth and continuing breastfeeding. In this narrative review, the literature on weighing breastfed babies in the United Kingdom is examined. A companion paper examined issues of growth charts, scales and weighing frequency and accuracy. This paper considers issues of interpretation of the plotted weight values for individual breastfed babies, noting the complexities of growth patterns, which may lead to difficulties of accurate identification of those individuals whose growth merits further investigation. Little attention has been given to issues of explaining the interpreted growth curves to parents and this issue is explored and noted as of importance for further study. Research evidence on choosing appropriate interventions to improve the growth of breastfed babies is reviewed. The paucity of such evidence leads to suggestions for future study. This review gathers together a wide range of literature from many different perspectives, with the hope of informing weight monitoring practice so that this can both identify infants whose weight may be of concern, and who may need appropriate intervention, and support continued breastfeeding.

Weight monitoring of breastfed babies in the UK - centile charts, scales and weighing frequency

Weighing infants during their first 6 months is an important focus of growth monitoring and a common activity of child health care services worldwide. In these same months, health workers provide support for breastfeeding and promote continued exclusive breastfeeding. The literature on the practice of weighing breastfed babies is reviewed, as it applies to the United Kingdom. The shape of the growth curves for breastfed babies differs from that of formula-fed infants and also from centile charts previously in use. The World Health Organization commitment to the production of a new growth reference has generated discussion of the implications of charts in use. The country-specific charts in use in the UK are examined and the data used to construct them discussed with reference to clinical use for breastfed infants. Recent UK discussions on charts, as well as on the frequency of routine weighing for babies in the community are considered, and the available evidence on the accuracy of weighing in practice is noted. The choices made in constructing different charts; the physical condition of scales and their use in practice have implications for plotted growth. This paper aims to present a wide range of evidence available in this area in order to encourage debate on practice. A companion paper will discuss issues of interpretation, conveying information to parents, and interventions.

Does familiarity breed acceptance? The influence of policy on physicians' attitudes toward newborn screening programs

OBJECTIVE

As newborn screening (NBS) programs expand to include conditions that challenge traditional public health criteria, little is known about what influences physicians' attitudes toward screening. We examined the effect of state policy and perceived state policy on pediatricians' attitudes toward screening.

METHODS

Six hundred pediatricians from the American Academy of Pediatrics who practiced in Wisconsin, Colorado, Florida, or Illinois were queried about (1) testing high-risk infants and (2) universal NBS for cystic fibrosis (CF), glucose-6-phosphate dehydrogenase deficiency (G6PD), and type 1 diabetes.

RESULTS

A total of 225 (41%) of 548 eligible pediatricians returned 223 surveys with usable data. The majority were supportive of NBS for CF (n = 188 [84%]) and G6PD (n = 130 [58%]), whereas only 25% (n = 55) supported type 1 diabetes screening. Pediatricians who lived in states that screen for a condition were more likely to support screening than those who lived in states that did not (CF: 117 of 119 [98%] vs 71 of 89 [80%]; type 1 diabetes: 32 of 88 [36%] vs 23 of 109 [21%]). Physicians also were more likely to support NBS when they believed that it was offered in their state versus when they believed that it was not (CF: 117 of 119 [98%] vs 52 of 65 [80%]; G6PD: 28 of 32 [88%] vs 75 of 108 [69%]; type 1 diabetes: 7 of 14 [50%] vs 25 of 102 [25%]).

CONCLUSIONS

Most pediatricians are supportive of NBS for CF and G6PD but not type 1 diabetes. Pediatricians who live in states that screen or believe that their states screen are more likely to support screening.

Developmental dysplasia of the hip: definition, recognition, and prevention of late sequelae

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.

Attitudes and beliefs of pediatricians and genetic counselors regarding testing and screening for CF and G6PD: Implications for policy

There is wide variability in conditions included in state newborn screening (NBS) panels. The American College of Medical Genetics (ACMG) was commissioned by Health Resources and Services Administration to develop a uniform NBS panel. Based on survey data, the ACMG committee proposed a panel that included cystic fibrosis (CF) and glucose-6-phosphate dehydrogenase deficiency (G6PD), although G6PD was excluded from their final recommendations. We examine the attitudes of pediatricians and genetic counselors concerning screening for these two conditions. Data were collected as part of two different studies. Koopmans and Ross surveyed a random sample of 600 pediatricians from four states based on their NBS panels. Hiraki et al. surveyed genetic counselors who were members of the National Society of Genetic Counselors (NSGC) listserv. For this analysis, we compare the health care professionals' (HCPs') attitudes toward a universal NBS program for CF and G6PD, and how their support is influenced by state policy and personal interest in testing their own children. Two hundred twenty-three pediatricians and 267 genetic counselors provided partial or complete responses. Pediatricians are more likely to support NBS for both CF (84%) and G6PD (58%) than genetic counselors (56%, P < 0.001 and 39%, P < 0.001, respectively). Both pediatricians and genetic counselors' attitudes toward screening correlate with interest in screening their own children (P < 0.001). Interest in CF screening also correlates with state policy (pediatricians, P < 0.001; genetic counselors, P < 0.025). The correlation of professional recommendations with state policies and personal preferences reinforces the need for systematic evidence-based reviews rather than reliance on stakeholder opinions for developing national guidelines.

Research for newborn screening: developing a national framework

Newborn metabolic screening represents the largest application of genetic testing in medicine. As new technologies are developed, the number of conditions amenable to newborn screening (NBS) will continue to expand. Despite the scope of these programs, the evidence base for a number of NBS applications remains relatively weak. This article briefly reviews the evidence base for several conditions. The article then develops a proposal for a structured sequence of research protocols to evaluate potential applications for NBS before their formal implementation in public health programs. Such a framework for research will require collaboration between states and the federal government, a collaboration that is emerging through recent federal legislation and funding.

Reassurance or judgement? Parents' views on the delivery of child health surveillance programmes

BACKGROUND

The first year of a child's life is a crucial time for child development. Current guidance about child health surveillance and health promotion programmes emphasises a partnership approach between health professionals and parents when it comes to child health care. Parents' voices have been largely absent from discussions about local child health programmes. For partnership working to be effective and for local services to be able to evolve effectively parents' views are vital.

OBJECTIVES

This study aimed to explore parents' views on the child health surveillance and health promotion programmes offered during the first year of their child's life. The study aimed to be consumer-led through the involvement of lead parents in all stages of the research process.

METHODS

This study employed a qualitative methodology of focus groups and individual interviews. 35 participants were drawn from three general practices using a snowball sampling technique. Eligibility was determined as parents with a child under the age of one year or expecting a baby within the study timescale and registered at one of the 3 general practices. Focus groups were led by three 'parent-researchers' and individual interviews were conducted by a researcher. All focus groups and interviews were tape-recorded, transcribed and analysed using Atlas.Ti.

RESULTS

Several main themes were identified in this study. Firstly, when discussing scheduled health checks for children under one year of age parents expressed more positive feelings for the eight-week check which was seen to be comprehensive and informative rather than the eight-month check which was viewed as bureaucratic and less reassuring. Secondly, parents clearly articulated a need for reassurance and support from health professionals involved in child health surveillance and health promotion programmes. Thirdly, a crucial professional in the delivery of these programmes was the health visitor. Whilst parents expressed support for the concept of health visitors some health visitors were seen as bureaucratic and as making judgements of need based on socio-economic factors. Finally, some parents spoke of feeling excluded from accessing support as they were deemed not to be 'in need'.

CONCLUSIONS

Wider concepts of partnership working between health professionals and parents, and, needs assessment are important to this study. Crucial elements of the partnership appear to be missing and this coupled with needs assessments that leave parents feeling excluded mean that there are discrepancies between expectations and experiences of parents. These issues require consideration in order to improve services and experiences.

Quality of care by neonatal nurse practitioners: a review of the Ashington experiment

The Ashington experiment, an innovative neonatal service run entirely by advanced neonatal nurse practitioners (ANNPs), has been evaluated. This is a report of that evaluation and a review of the benefits, hazards, and implications of nurse practitioner led services.

The cost effectiveness of universal versus selective newborn screening for sickle cell disease in the US and the UK: a critique

We reviewed several cost-effectiveness analyses that modelled the costs and yield of newborn screening for sickle cell disease (SCD) in the US and the UK and discuss the ways in which newborn screening policies in each country evolved with regard to the results of the analyses. Each of the reviewed studies compared the projected cost of universal screening with that of selective screening of children from specific ethnic groups. Despite variability in assumptions, the studies concurred that universal screening in areas with low SCD prevalence would result in a higher cost per case detected, compared with selective screening of children in high-risk ethnic groups. Investigators expressed differing opinions about the economic justification of universal screening, which reflected differences in the understanding of cost effectiveness and in how study questions were framed. Ultimately, policy makers in both countries decided in favour of universal screening, which appears to reflect a growing consensus that ethnically targeted newborn screening is not an acceptable public health strategy. One way to interpret this outcome is that considerations of equity and logistics, including potential stigmatisation, missed cases, and the perceived difficulty and discomfort in ascertaining ethnicity or in separating specimens, trumped economic calculations regarding the relative efficiency of targeted screening. It is not the case that policy makers explicitly favoured equity over economic optimisation; rather, they appear to have given more credence and value to the expert opinion of screening specialists than to the results of economic analyses.

Vision Health Care Providers?? Attitudes and Experiences with Preschool Vision Screening in Ontario

PURPOSE

The validity of preschool vision screening has been questioned in the light of the World Health Organization's criteria for determining the validity of screening programs. However, recommendations toward preschool screening have been made by a number of organizations. Given the contrasting views of screening, the purpose of this study was to examine visual health care provider experiences and attitudes toward preschool screening.

METHOD

Optometrists, public health administrators, pediatric ophthalmologists, and orthoptists were surveyed about opinions of, recommendations for, and experiences with preschool vision screening in Ontario. The survey focused on four areas, including general opinion of preschool screening, screening standards and practices, provider experience with preschool screening, and barriers to preschool screening. In addition, survey responses were broken down by regional access to health care.

RESULTS

Overall, strong support for preschool vision screening and movement toward standardization of screening practice was found among all surveyed groups. Although support for vision screening in low health care access areas was strong, providers estimated that parent compliance to screening was weaker in low access areas. Providers also reported considerable variability in vision screening practices. In addition, although the majority of providers had been involved in a screening program, the majority was no longer involved because of lack of program organization, structure, and funding. Lack of sufficient funding, public education, organization of screening, training, and government support were listed as barriers to preschool vision screening.

CONCLUSION

Providers are interested in the development of structured screening programs. However, although screening may be a way to offer some level of vision care service to low health care access areas, a number of factors need to be addressed in discussions of vision screening program standards or screening best practice. In general, preschool screening programs need to be structured, be supported, have quality control, and be evaluated.

Newborn screening for medium chain acyl-CoA dehydrogenase deficiency: evaluating the effects on outcome

Although individually rare, inborn errors of metabolism represent a potentially preventable cause of death and disability. Tandem mass spectrometry allows a number of these disorders to be detected in a single step. Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is the most important of these disorders. However, public health decisions on whether or not to implement new screening programmes rely on evidence regarding benefits and harms. This article reviews existing published evidence for newborn screening for MCADD and highlights where further information is required for public health decision making. This review reveals that important uncertainties remain about performance and outcome, including criteria and thresholds for defining a positive screening result, diagnostic criteria, test performance and longer-term outcome. Notably, despite a combined experience of screening well over one million infants, there has been no report of a systematic follow-up of longer-term outcome in affected infants detected by screening. Prospective data on mortality, neurological outcome, and cognitive function are required to assess the effectiveness of screening. Additionally, the impact of screening and treatment on the families of infants with true, borderline, and false positive diagnoses needs to be taken into account.

Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial

BACKGROUND

Clinical screening aims to identify and treat neonatal hip instability associated with increased risk of hip displacement, but risks failures of diagnosis and treatment (abduction splinting), iatrogenic effects, and costs to parents and health services. Our objectives were to assess clinical effectiveness and net cost of ultrasonography compared with clinical assessment alone, to provide guidance for management of infants with clinical hip instability.

METHODS

Infants with clinical hip instability were recruited from 33 centres in UK and Ireland and randomised to either ultrasonographic hip examination (n=314) or clinical assessment alone (n=315). The primary outcome was appearance on hip radiographs by 2 years. Secondary outcomes included surgical treatment, abduction splinting, level of mobility, resource use, and costs. Analysis was by intention to treat.

FINDINGS

Protocol compliance was high, and radiographic information was available for 91% of children by 12-14 months and 85% by 2 years. By age 2 years, subluxation, dislocation, or acetabular dysplasia were identified by radiography on one or both hips of 21 children in each of the groups (relative risk 1.00; 95% CI 0.56-1.80). Fewer children in the ultrasonography group had abduction splinting in the first 2 years than did those in the no-ultrasonography group (0.78; 0.65-0.94; p=0.01). Surgical treatment was required by 21 infants in the ultrasonography group (6.7%) and 25 (7.9%) in the no-ultrasonography group (0.84; 0.48-1.47). One child from the ultrasonography group and four from the no-ultrasonography group were not walking by 2 years (0.25; 0.03-2.53; p=0.37). Infants in the ultrasonography group incurred significantly higher ultrasound costs over the first 2 years (pound 42 vs pound 23, mean difference pound 19, 95% CI 11-27); total hospital costs were lower for those infants, but the difference was not significant.

INTERPRETATION

The use of ultrasonography in infants with screen-detected clinical hip instability allows abduction splinting rates to be reduced, and is not associated with an increase in abnormal hip development, higher rates of surgical treatment by 2 years of age, or significantly higher health-service costs.