Congenital cytomegalovirus (cCMV) is the leading viral cause of birth defects and a major contributor to pediatric hearing loss. Universal newborn screening has gained momentum in recent years, expanding access to early screening and intervention; however, misconceptions about transmission have also led some daycare centers to turn away children with a history of cCMV, even though acquired CMV infections are generally asymptomatic. This practice is especially concerning in states with universal newborn screening, such as Minnesota, where more asymptomatic carriers are identified. Exclusion policies are not supported by evidence and put extra strain on families with fewer resources, raising pressing equity concerns. A more effective and just approach is the education of daycare staff and caregivers on preventive measures, including hand hygiene, protective equipment, and avoidance of direct contact with bodily fluids. Both public health education and policy reform are needed to correct misconceptions, protect vulnerable populations, and prevent discriminatory practices that perpetuate the stigmatization of children with cCMV.
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August 2026Introduction
In the U.S, vertical transmission of CMV is the leading viral cause of birth defects and can result in hearing loss, developmental delay, and vision impairment in newborns (Matern Child Health J. doi:10.1007/s10995-013-1275-0). After infancy, however, immunocompetent individuals who contract CMV are generally asymptomatic or experience only mild symptoms (Matern Child Health J. doi:10.1007/s10995-013-1275-0). Despite CMV being a common infection, studies show that awareness of CMV remains limited in both the medical community and the general public (Infect Dis Obstet Gynecol. doi:10.1155/IDOG/2006/80383). Misunderstandings about CMV have even resulted in some children being turned away from daycare due to their cCMV status (Pediatrics. doi:10.1542/peds.75.5.971).
As universal newborn screening expands through federal initiatives like the STOP CMV Act—currently being considered by Congress to authorize federal funding for cCMV screening—more children with asymptomatic cCMV are being identified, which highlights the urgent need for clear, evidence-based daycare policies and public health education (AAO-HNS. https://tinyurl.com/5cts82as). While universal screening will improve early detection, reduce delays in audiology referral for hearing loss, and decrease long-term morbidity, these policies may also introduce some unintended downstream effects if not paired with clear public health guidance.
In this commentary, we examine the public health implications and ethical concerns raised by exclusionary practices and suggest some harm reduction strategies that acknowledge transmission risk while preventing stigma and discrimination.
Prevalence and Transmission
By age five, about one in three children have already been infected by CMV, and by age 40, more than 50% of adults have acquired the virus (CDC. https://tinyurl.com/2cv9uzpx). Pregnant individuals who become infected with CMV are at risk of vertical transmission to their baby, making CMV a notable public health concern.
The virus spreads through bodily fluids such as saliva and urine, making close-contact environments particularly conducive to transmission (Rev Med Virol. doi:10.1002/rmv.695). Daycare settings, in particular, have high transmission rates, with more than 30% of children showing evidence of current or past CMV infection, reflecting frequent close contact among young, often asymptomatic children (Rev Med Virol. doi:10.1002/rmv.2011).
Notably, the virus can be shed for months to years after initial CMV infection, whether congenitally or postnatally acquired, so both groups of children may contribute to transmission long after the acute illness has resolved. The high background prevalence of shedding highlights why exclusion policies targeting children with cCMV are unlikely to meaningfully reduce overall transmission risk in daycare settings.
Ethical Considerations: Exclusion of CMV-Positive Children
Although immunocompetent children and staff generally experience mild or no symptoms if infected with CMV, misconceptions about who is at risk for severe outcomes remain widespread among the general public and daycare communities. Some daycares, both historically and currently, have responded by excluding children with a history of cCMV (Pediatrics. doi:10.1542/peds.75.5.971). As universal screening expands, more asymptomatic carriers will be identified, which highlights the need for policies that align with evidence (Minnesota Department of Health. https://tinyurl.com/bdzfyf5e). Exclusion based on past infection raises concerns about discrimination and sets a troubling precedent for other stigmatized infectious diseases, such as HIV. Additionally, CMV disproportionately affects families with fewer socioeconomic resources and certain racial/ethnic minorities (J Paediatr Child Health. doi:10.1111/jpc.12502). This highlights an important health justice issue, as families with fewer resources are then more likely to face exclusion and may be forced to withdraw their children from daycare, leading to compounding opportunity costs related to employment and economic stability.
Prevention in Daycare Settings
The National CMV Foundation advises against excluding children with cCMV from daycare, as a high number of children in these settings have been exposed to CMV and may be shedding the virus at any given time (National CMV Foundation. https://tinyurl.com/39dw8vfz). As such, exclusion policies do not necessarily meaningfully reduce transmission and lack an evidence-based approach. Importantly, these concerns are not an argument against universal CMV screening itself. Early identification of cCMV enables monitoring, early intervention, and the potential to mitigate long-term sequelae such as hearing loss and developmental delay. Instead, we suggest that a more effective approach is to equip daycare staff and caregivers with knowledge of preventive strategies (Aust N Z J Obstet Gynaecol. doi:10.1111/ajo.70016). These include frequent and effective hand hygiene, avoiding direct contact with bodily fluids, using protective equipment during diaper changes, and refraining from kissing children. Staff should also discourage behaviors that increase exposure, such as sharing food, cups, or utensils, both among children and between children and pregnant caregivers.
Because young children may not consistently adhere to preventive strategies, a harm reduction approach focused on staff training, parent education, and consistent hygiene practices offers more realistic ways to cumulatively reduce transmission risk (Aust N Z J Obstet Gynaecol. doi:10.1111/ajo.70016; Appl Environ Microbiol. doi:10.1128/AEM.03262-13). These approaches have proven effective for pregnant individuals as well—a systematic review showed that CMV seroconversion rates were significantly lower after implementation of hygiene-based practices and educational interventions (BMC Pregnancy Childbirth. doi:10.1186/s12884-024-06367-5). While interventions may require modest resource investments, such as additional training time or improved access to handwashing stations, they offer a more equitable and evidence-based approach than exclusionary policies. Overall, prioritizing education, hygiene infrastructure, and precautions offers a practical framework that acknowledges the realities of childcare settings while mitigating transmission risk and preventing unnecessary exclusion of children with cCMV.
Conclusion
Daycare exclusion policies for children with cCMV lack scientific justification and exacerbate inequities for vulnerable families. As access to universal screening increases and more children are identified with cCMV, the need for evidence-based guidance also grows more urgent. Otolaryngologists, pediatricians, obstetrician–gynecologists, and public health leaders must advocate for public education and policy reform to address misconceptions, share prevention strategies, and prevent exclusion of children from daycare based on cCMV infection.
Dr. Jayawardena is a pediatric otolaryngologist at Children’s Minnesota and an associate professor in the department of otolaryngology–head and neck surgery at the University of Minnesota Medical School, both in Minneapolis. He specializes in pediatric hearing, breathing, swallowing, and sleep disorders.
Dr. Meyer is a pediatric otolaryngologist and senior medical director of surgical specialties at Children’s Minnesota and an assistant professor in the department of otolaryngology–head and neck surgery at the University of Minnesota Medical School, both in Minneapolis. She specializes in pediatric hearing loss, chronic ear disease, and fetal airway disorders.
Dr. Zhou is a recent graduate of the University of Minnesota Medical School in Minneapolis and an incoming OB/GYN resident at the University of California, San Francisco. She is passionate about serving the deaf and hard-of-hearing community, health equity, advocacy, and interdisciplinary perinatal care.
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