The New York State universal newborn hearing screening demonstration project: outpatient outcome measures

High Prevalence of Cochlear Nerve Deficiency in Pediatric Patients With Cochlear Aperture Stenosis

OBJECTIVE

Cochlear nerve deficiency (CND) is a common radiologic finding among unilateral sensorineural hearing loss (USNHL) patients. It is generally detected with magnetic resonance imaging (MRI), which is associated with higher cost, less availability, and possible need for sedation. Therefore, identifying computed tomography (CT) findings, such as cochlear aperture stenosis (CAS), that can reliably predict CND is valuable. Our study aimed to determine the prevalence of CND in pediatric patients with CT-diagnosed CAS.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care center.

METHODS

We included pediatric patients diagnosed with CAS on temporal bone CT and with available temporal bone MRI. For each patient, an otolaryngologist and a pediatric neuroradiologist measured the cochlear aperture width on CT to confirm CAS (cochlear aperture < 1.4 mm) and assessed the status of the cochlear nerve on MRI.

RESULTS

Fifty-five patients, representing 65 ears, had CAS on CT measurement. Median cochlear aperture width in CAS ears was 0.70 mm (interquartile range [IQR]: 0.40-1.05 mm) versus 2.00 mm in non-CAS ears (IQR: 1.80-2.30 mm, P < .001). CND was found in 98.5% (n = 64/65) of CAS ears, while a normal cochlear nerve was found in 1.5% (n = 1/65) of CAS ears.

CONCLUSION

CND is highly prevalent among pediatric patients with CAS. This suggests that MRI may not be needed to assess for CND in USNHL patients with CAS, as initial CT may provide sufficient information to determine cochlear implant candidacy. We recommend thoughtful shared decision-making with parents of USNHL patients when determining whether to pursue MRI in the setting of a CAS diagnosis.

An Absorbance Peak Template for Clinical Assessment of Sound Conduction in Newborn Ears

PURPOSE

Power absorbance measures recorded over a wide range of frequencies allow for clinical inferences about the outer/middle ears' acoustic mechanics. A frequency-dependent feature in the newborn wideband absorbance response, the prominent mid-frequency absorbance peak, has been linked to middle-ear resonance. However, current normative methods were not designed to assess subtle changes in such features. This work aims to develop and validate an absorbance peak template (APT) for assessment of absorbance peaks in newborns. Additional objectives are to compare test performance of absorbance peaks and APTs to existing normative methods, to demonstrate APT-based methods for categorization of abnormal absorbance peaks, and to describe absorbance peak test-retest variability.

METHOD

Peak absorbance and peak frequency were analyzed in a training data set (490 measurements in 84 newborn ears who passed transient evoked otoacoustic emissions [TEOAEs] screenings), and an APT was developed by computing normal limits on these two absorbance peak variables. Split-set analysis evaluated the reproducibility of APT, and test-retest analysis was performed. Test performance analysis, conveyed by area under the receiver operating characteristic curve (AROC) and 95% confidence intervals (CIs), compared absorbance peak variables to absorbance area indices (AAIs) in a validation data set (359 ears that passed distortion-product OAE [DPOAE] screening and 64 ears that failed). APT-based assessment paradigms for normal and abnormal ears were compared to the common absorbance normative range paradigm.

RESULTS

Split-set analysis demonstrated a good reproducibility of APT, and test-retest of absorbance peak variables showed that they were stable measures for clinical assessment. Test performance of peak absorbance (AROC = 0.83; 95% CI [0.77, 0.88]) was comparable to the top-performing AAI variables (AROC = 0.85; 95% CI [0.80, 0.90]). APT-based assessment categorized measurements based on their peak absorbance and peak frequency and enhanced the detection of subtle frequency changes that were missed by the normative range method.

CONCLUSION

Analysis of absorbance peaks guided by APT has the potential to simplify and improve assessments of sound conduction pathways in newborn ears and can be used together with or in-place of current methods for analysis of wideband absorbance data.

The Complexity of Hearing Aid Fitting: Children with Congenital Hearing Loss and Middle Ear Dysfunction

BACKGROUND

The early diagnosis of hearing loss (HL) and hearing rehabilitation facilitate language and communication development. Some children exhibit mixed HL due to middle ear effusion (MEE) or acute otitis media (AOM). Mixed HL can affect HL evaluation and hearing aid (HA) fitting. The present study retrospectively evaluated the prevalence of MEE/AOM among children with congenital sensorineural HL (SNHL) who were fitted with HAs and its effect on the HA fitting.

METHODS

Thirty-six HA fittings carried out between 2017 and 2020 at one rehabilitation center were examined. Medical and audiological information was retrieved for children between 6 and 32 months old. The number of appointments and HA fitting times were recorded.

RESULTS

Twenty-eight children were included in the study. Eighteen children, in addition to SNHL, had a conductive component resulting from MEE/AOM. The children with these pathologies required significantly more HA fitting sessions and hearing tests, fewer real ear to coupler difference (RECD) measurements and longer HA fitting periods.

CONCLUSION

The findings indicate that a large number of children fitted with HAs have an additional conductive component that makes the fitting process longer. Since early rehabilitation is necessary for language development, otolaryngologists should be aware of the adverse effects of MEE/AOE on the HA fitting process. It is important to inform parents that when there is a conductive component, the HA fitting process may take longer and that treatment by an otolaryngologist is vital. This study stresses the importance of multidisciplinary cooperation for optimal HA fitting.

Sociodemographic Factors Affecting Loss to Follow-Up After Newborn Hearing Screening: A Systematic Review and Meta-Analysis

OBJECTIVE

Universal newborn hearing screening (NBHS) has been widely implemented as a part of early hearing detection and intervention (EHDI) programs worldwide. Even with excellent provider knowledge and screening rates, many infants do not receive definitive hearing testing or intervention after initial screening. The objective of this study was to identify sociodemographic factors contributing to loss of follow-up.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the databases were searched from the date of inception through December 28, 2021. Studies containing sociodemographic information on patients who were referred to NBHS were included. Meta-analysis of odds ratios (ORs) was performed comparing rates of sociodemographic variables between patients adherent and nonadherent to follow-up.

RESULTS

A total of 169,238 infants from 19 studies were included. Low birth weight (OR 1.6 [95% confidence interval, CI 1.2-2.2, p < .001), racial minority (OR 1.4 [95% CI 1.2-1.6], p < .001), rural residence (OR 1.5 [95% CI 1.1-1.9], p = .005), lack of insurance (OR 1 [95% CI 1.4-2.5], p < .001), and public or state insurance (OR 1.7 [95% CI 1.2-4.2], p = .008) were associated with missed follow-up after referred NBHS. Associated maternal factors included low maternal education (OR 1.8 [95% CI 1.6-2.0], p < .001), young maternal age (OR 1.5 [95% CI 1.5-1.6], p < .001), unmarried maternal status (OR 1.5 [95% CI 1.1-1.9], p = .003), and current or former maternal smoking status (OR 1.8 [95% CI 1.4-2.2], p < .001).

CONCLUSION

Both infant and maternal sociodemographic factors influence follow-up compliance after referred NBHS. Focused efforts should be made by medical providers and policymakers to address these factors to ensure appropriate newborn hearing care and interventions are achieved.

Use of Wideband Acoustic Immittance in Neonates and Infants

With widespread agreement on the importance of early identification of hearing loss, universal newborn hearing screening (UNHS) has become the standard of care in several countries. Despite advancements in screening technology, UNHS and early hearing detection and intervention programs continue to be burdened by high referral rates of false-positive cases due to temporary obstruction of sound in the outer/middle ear at birth. A sensitive adjunct test of middle ear at the time of screening would aid in the interpretation of screening outcomes, minimize unnecessary rescreens, and prioritize referral to diagnostic assessment for infants with permanent congenital hearing loss. Determination of middle ear status is also an important aspect of diagnostic assessment in infants. Standard single-frequency tympanometry used to determine middle ear status in infants is neither efficient nor accurate in newborns and young infants. A growing body of research has demonstrated the utility of wideband acoustic immittance (WAI) testing in both screening and diagnostic settings. Wideband power absorbance (WBA), a WAI measure, has been shown to be more sensitive than tympanometry in the assessment of outer/middle ear function in newborns. Furthermore, age-graded norms also support successful application of WBA in young infants. Despite its merits, uptake of this technology is low among pediatric audiologists and hearing screening health workers. This report describes normative data, methods for assessment and interpretation of WBA, test-retest variations, and other factors pertinent to clinical use of WAI in newborns and infants. Clinical cases illustrate the use of WAI testing in newborn and infant hearing assessment.

Results and patient satisfaction from an early access infant hearing detection clinic

INTRODUCTION

National recommendations in the United States specify that all infants with hearing impairment should be identified by 3 months of age. Infants who fail universal newborn hearing screening (UNHS) require follow up testing after hospital discharge. Follow up testing may be difficult to obtain in some communities within the ideal time frame. A rapid access multidisciplinary clinic was established for failed UNHS. The objective of this study is to report outcomes and patient satisfaction from an early access hearing detection clinic.

METHODS

Infants that failed UNHS were seen in the multidisciplinary clinic between 1/1/19 and 2/28/22. Patients underwent automated auditory brainstem response (ABR) and distortion product otoacoustic emissions testing and consulted with an otolaryngology nurse practitioner. Failed results were followed by diagnostic ABR. Surveys were administered at the beginning and end of the appointment.

RESULTS

In total, 169 infants were seen at a mean age of 8.4 weeks (95%CI 7.5, 9.4). Repeat testing was abnormal in 38 (22.4%). Diagnostic ABR was performed at an average age of 13.7 weeks (n = 34, 95% CI: 10.8, 16.6) and led to a diagnosis of hearing loss in 18 infants. Twenty-seven parents completed surveys at the initial visit. Anxiety level among patients with normal repeat testing (n = 20) decreased from 1.9 to 1.2 (p = .002), while anxiety level among those with abnormal repeat testing (n = 7) was not statistically different before and after (2.1 vs 2.7, p = .2). Satisfaction level was 3.7 ± 0.7 (scored 1-4). All parents reported having a better understanding of their child's hearing problem after the visit.

DISCUSSION

This novel nurse practitioner-led early hearing detection clinic enabled timely diagnosis of hearing loss and reassurance to families without hearing loss. Age at hearing loss diagnosis compares favorably to published cohorts.

"Association of High Risk Factors and Hearing Impairment in Infants-A Hospital Based Study"

The aim of the study was to find the association of various risk factors with permanent hearing impairment in infants. A case-control study was designed on 420 infants with permanent hearing impairment and normal hearing. The case control ratio was 1:1. Alternate sampling method was used for selecting the control group. Review of medical records and parent interview was done to collect the information of risk factors. Family history(adj. OR 7.5; 95% CI 3, 14; P = 0.000), Consanguinity (adj. OR: 4; 95% CI 2,4; P = 0.000), intra uterine infection (adj. OR 18, 95% CI: 2.3-126.5, P = 0.000), post natal infection (adj. OR 3, 95% CI: 1.3-5, P = 0.004), low Apgar score (adj.OR: 4.6, 95% CI: 1.3-15), craniofacial anomaly (OR-4.6, 95% CI: 1.4-9.5, P = 0.005) and low birth weight (adj. OR: 2.3, 95% CI: 1.2-3.8) were significantly associated with hearing impairment. Among the risk factors, intra uterine infection was having highest significant association with permanent hearing impairment. This is followed by family history, low Apgar score, craniofacial anomaly, consanguinity, post natal infection and low birth weight.

A novel heterozygous SIX1 missense mutation resulted in non-syndromic unilateral hearing loss

Familial non-syndromic unilateral hearing loss (NS-UHL) is rare and its genetic etiology has not been clearly elucidated. This study aimed to identify the genetic cause of NS-UHL in a three-generation Chinese family. Detailed medical history consultation and clinical examination were conducted. Further, whole-exome sequencing (WES) was performed to identify the genetic etiology of the proband, and the variant was verified by Sanger sequencing. A novel missense mutation, c.533G>C (p.Arg178Thr), in the SIX homeobox 1 gene (SIX1) was identified in four patients and co-segregated with NS-UHL in a three-generation Chinese family as a dominant trait. Using bioinformatics analyses, we show that this novel mutation is pathogenic and affects the structure of SIX1 protein. These data suggest that mutations in SIX1 gene are associated with NS-UHL. Our study added the NS-UHL phenotype associated with SIX1, and thereby improving the genetic counseling provided to individuals with SIX1 mutations.

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

Background

An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.

Methods

Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.

Results

Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.

Conclusion

Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03218-0.

Newborn Hearing Screening Benefits Children, but Global Disparities Persist

There is substantial evidence that newborn hearing screening (NHS) reduces the negative sequelae of permanent childhood hearing loss (PCHL) if performed in programs that aim to screen all newborns in a region or nation (often referred to as Universal Newborn Hearing Screening or UNHS). The World Health Organization (WHO) has called in two resolutions for the implementation of such programs and for the collection of large-scale data. To assess the global status of NHS programs we surveyed individuals potentially involved with newborn and infant hearing screening (NIHS) in 196 countries/territories (in the following text referred to as countries). Replies were returned from 158 countries. The results indicated that 38% of the world's newborns and infants had no or minimal hearing screening and 33% screened at least 85% of the babies (hereafter referred to as UNHS). Hearing screening programs varied considerably in quality, data acquisition, and accessibility of services for children with PCHL. In this article, we summarize the main results of the survey in the context of several recent WHO publications, particularly the World Report on Hearing, which defined advances in the implementation of NHS programs in the Member States as one of three key indicators of worldwide progress in ear and hearing care (EHC).

Multiple congenital anomalies and adverse developmental outcomes are associated with neonatal intensive care admission and unilateral hearing loss

AIM

To determine congenital and developmental outcomes of children with Unilateral Hearing Loss (UHL) who were admitted to the Neonatal Intensive Care Unit (NICU).

METHOD

Retrospective, single-site study that followed 25 children with permanent congenital UHL and a NICU admission to a NICU of Nottingham University Hospital. Birth and two-year developmental follow-up data were collected. They were compared to matched control group who had a NICU admission but no hearing loss (matched on gestational age, weight and sex).

RESULTS

The median birthweights, gestational ages and number of days spent on the NICU for the UHL population were 2510 g, 36 weeks, and 12 days respectively. Most children (20/25; 80%) with UHL and a NICU admission were diagnosed with a congenital anomaly within the first two years of life. Only half (13/25) of these children were diagnosed with a congenital anomaly at discharge. Children with UHL and a NICU admission were more likely than the matched group (NICU admission only; p < .001) to have multiple congenital anomalies. We found a positive association between multiple congenital anomalies and developmental impairment for the NICU graduates with UHL (p = .019). This UHL-NICU group were also more likely than the matched NICU children to have developmental impairment (7/25 vs. 0/25; p = .01), speech and language therapy (13/25 vs. 1/25; p < .001), inner ear malformations (14/25 vs. 0/25, p < .001) or craniofacial anomalies (12/25 vs. 2/25; p = .004).

INTERPRETATION

Children with UHL and a NICU admission were at high risk of congenital anomalies and certain adverse developmental outcomes. Improved congenital anomaly screening is needed at birth for this population. Having multiple congenital anomalies suggests closer developmental monitoring is needed. This study contributes towards producing clinical screening and management guidelines to ensure consistent high-quality care for this unique population.

Assessing Loss to Follow-up After Newborn Hearing Screening in the Neonatal Intensive Care Unit: Sociodemographic Factors That Affect Completion of Initial Audiological Evaluation

OBJECTIVES

Neonatal intensive care unit (NICU) patients are at high risk for congenital hearing loss. Previous studies have found sociodemographic factors associated with loss to follow-up for newborn hearing screening, but none have specifically studied the NICU population. Our objective is to determine if demographics and socioeconomic status is associated with loss to follow-up in a newborn population with extended NICU stay.

DESIGN

A retrospective cohort study was conducted on 443 NICU infants with extended NICU stay utilizing data extracted from infant and maternal medical records at an urban safety-net hospital.

RESULTS

Younger maternal age (adjusted odds ratio [OR] 0.95, confidence interval [CI] 0.91 to 0.99), higher gravidity (adjusted OR 1.39, CI 1.12 to 1.72), and former smoking status (adjusted OR 2.57, CI 1.07-6.18) were identified as independent predictors of loss to follow-up for NHS after conducting a multivariable logistic regression. Demographic and socioeconomic variables, such as sex, parity, birth weight, mode of birth, highest level of maternal education, maternal race/ethnicity, zip code metrics, and maternal language were not found to be associated with loss to follow-up.

CONCLUSIONS

Maternal age, gravidity, and smoking status are risk factors for loss to follow-up for NHS in newborns with extended NICU stay, a group at high risk for hearing loss. Our findings demonstrate that socioeconomic and demographic factors for loss to follow-up in the extended-stay NICU population are distinct from the well-baby population. Further investigation of these patients will allow prioritization of limited resources to subgroups within the extended-stay NICU population at risk for loss to follow-up for newborn hearing screening.

The History of Pediatric and Adult Hearing Screening

OBJECTIVES/HYPOTHESIS

To document the history of hearing seeing in children and adults.

STUDY DESIGN

A literature search in all languages was carried out with the terms of hearing screening from the following sources: Pub Med, Science Direct, World Catalog, Index Medicus, Google scholar, Google Books, National Library of Medicine, Welcome historical library and The Library of Congress.

METHODS

The primary sources consisting of books, scientific reports, public documents, governmental reports, and other written material were analyzed to document the history of hearing screening.

RESULTS

The concept of screening for medical conditions that, when found, could influence some form of the outcome of the malady came about during the end of 19th century. The first applications of screening were to circumscribe populations, schoolchildren, military personnel, and railroad employees. During the first half of the 20th century, screening programs were extended to similar populations and were able to be expanded on the basis of the improved technology of hearing testing. The concept of universal screening was first applied to the inborn errors of metabolism of newborn infants and particularly the assessment of phenylketonuria in 1963 by Guthrie and Susi. A limited use of this technique has been the detection of genes resulting in hearing loss. The use of a form of hearing testing either observational or physiological as a screen for all newborns was first articulated by Larry Fisch in 1957 and by the end of the 20th century newborn infant screening for hearing loss became the standard almost every nation worldwide.

CONCLUSIONS

Hearing screening for newborn infants is utilized worldwide, schoolchildren less so and for adults many industrial workers and military service undergo hearing screening, but this is not a general practice for screening the elderly.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:S1-S25, 2021.

Newborn hearing screening programme based on an integrated hospital and community care system. Results of the first 4 years of activity

Since January 2012, babies born in the province of Modena, Italy, have routinely undergone hearing testing as part of a two-stage screening programme. Newborn hearing screening (NHS) has been based on an integrated hospital and community care system and this study aims to assess screening coverage, referral rates, the prevalence, type and extent of hearing loss several years into the programme. Data were collected from January 1, 2012 to December 31, 2015. Coverage was over 99% in all five facilities of the province. The ratio of "fails of the screening" to the total number of infants tested varied over the period from 1.2% to 0.9% in the third level facility, and from 0.8% to 0.4% in the other four. Although hearing loss was mainly associated with dysmorphic\syndromic diseases or a family history of hearing loss, some 23% of cases were identified with no known risk factors. We highlight the importance of the NHSP and the need for strong support from healthcare administrators to ensure high coverage. This is especially true since although the prevalence of hearing loss was higher among infants with audiological risk factors, several cases of hearing loss were found in newborns with no known risk factors.

Hearing screening outcome in neonatal intensive care unit graduates from a tertiary care centre in Singapore

BACKGROUND

We aimed to analyse the outcome of universal newborn hearing screening (UNHS) and high-risk hearing screening in neonatal intensive care unit (NICU) graduates in a tertiary care unit.

METHODS

The hearing screen programme comprises a 2-stage automated auditory brainstem response protocol followed by a high-risk hearing screen at 3-6 months. This study is a retrospective study of NICU graduates born between April 2002 and December 2009. Data on hearing screening, audiological assessment, and management were extracted from a computerized data management system (HITRACK).

RESULTS

Of 100,225 newborn infants, 2.9% were admitted to the NICU during the study period. The overall incidence of hearing loss (HL) of any type/severity was 35/1,000 infants. Of infants with HL, 92.4% had their first automated auditory brainstem response at/before 1 month of corrected age. The incidence of congenital permanent HL identified by the UNHS was 15.4/1,000. The corrected median age of diagnosis was 4.5 months (1-23.5 months). Of 2,552 NICU graduates who passed the UNHS, 75.5% were retested at 3-6 months of life. Twelve infants with permanent late-onset HL were identified, raising the overall incidence of permanent HL to 19.9/1,000; 1.1/1,000 had auditory neuropathy. Of the 92 infants with HL, 89 (96.7%) had multiple risk factors.

CONCLUSIONS

There is a high incidence of HL in NICU graduates; 22.6% were late in onset. An early rescreen in those who pass the UNHS is a beneficial step for this high risk population.

The Role of Audiologists in Assuring Follow-Up to Outpatient Screening in Early Hearing Detection and Intervention Systems

PURPOSE

The purpose of this study was to investigate the role of audiology involvement and other factors associated with failure to follow through from the initial hearing screening to the second outpatient screen.

METHOD

Linear regression, logistical regression, and descriptive analyses were used across demographic and hospital variables associated with infants who did not receive a follow-up outpatient screen.

RESULTS

The results included birthing hospital outpatient rescreen rates from January 1, 2005, through December 31, 2005. Variables were collected from the birth certificate and hospital surveys. Results showed higher loss to follow-up/documentation to outpatient screen for (a) infants born in hospitals with low rates for returning for follow-up, (b) infants born in hospitals that did not have an audiologist involved, (c) infants who were Hispanic, (d) infants who were born to mothers who were not married, (e) infants with mother's with < 12 years of education, and (f) infants with Apgar scores of 7 or below.

CONCLUSIONS

The findings were used to identify quality improvement strategies to decrease the loss to follow-up. Strategies included ensuring audiology support, providing information in the parent's native language, educating personnel in the newborn intensive care units, developing and disseminating information in Spanish in written form, and educating hospitals on the importance of scheduling the outpatient rescreening before hospital discharge.

Prevalence and Social Risk Factors for Hearing Impairment in Chinese Children-A National Survey

Hearing impairment may affect children’s communication skills, social development, and educational achievement. Little is known about the prevalence of hearing impairment among Chinese children. Data were taken from the 2006 second China National Survey on Disability (CNSD). Hearing impairment was defined as moderate (41–60 dB HL), severe (61–80 dB HL), profound (81–90 dB HL), or complete (>91 dB HL). Logistic regression was used to estimate the odds ratio (OR) and 95% confidence intervals (CI). A weighted number of 567,915 hearing impairment children were identified, yielding a prevalence of 17.49 per 10,000 people (95% CI: 16.90–18.08), with prevention or treatment options possible for 64.6% of hearing impairment children. The main causes of hearing impairment were hereditary, tympanitis, and drug intoxication. Illiteracy in one or both parents (mother: OR = 1.388, 95% CI: 1.125–1.714, p < 0.0001; father: OR = 1.537, 95% CI: 1.152–2.049, p < 0.0001 relative to no school or primary school), annual family income lower than national average (OR = 1.323, 95% CI: 1.044–1.675, p = 0.0203, relative to higher than national average), household size larger than three people (OR = 1.432, 95% CI: 1.164–1.762, p = 0.0007, relative to smaller than three people) and single-mother family (OR = 2.056, 95% CI: 1.390–3.042, p = 0.0176, relative to intact family) were the independence risk factors for hearing impairment among Chinese children. Lower annual family income, male children, larger household size, single-mother family, and lower levels of maternal and paternal education were independent risk factors for hearing impairment for Chinese children. Further studies on hearing impairment prevention and the relationship between parental social factors and the risk of hearing impairment are needed.

Follow-up in newborn hearing screening - A systematic review

INTRODUCTION

The quality and efficiency of newborn hearing screening programs (NHS) rely heavily on appropriate follow-up. The Joint Committee on Infant Hearing recommends a follow-up rate of more than 95% of infants who fail the initial hearing screening. However, a 70% benchmark is considered to be more feasible. This high loss to follow-up (LTF) rate acts as a threat to the overall success of NHS programs. The objective of the study was to identify and examine the reported rates of LTF, attributed reasons for LTF and strategies undertaken to reduce LTF.

METHODS

Using a systematic search, articles published between 2005 to December 2015 were identified from PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Educational Resources Information Center (ERIC), Scopus, Ovid, ProQuest, and Cochrane Library. To be included in the review, the study should be exploring the loss to follow-up or drop-out rate in newborn hearing screening programs and be published in an indexed peer-reviewed journal in the English language. The main outcome measures were overall rate of LTF, factors leading to LTF and measures adopted to overcome LTF.

RESULTS

53 articles were short-listed for data extraction. Out of these, 27 were single-centre studies, 19 were multi-centre, 3 compared multiple databases, and 4 used survey-based methods. Overall LTF rates of 20% in single-centre and 21% in multiple-centre studies were observed. Educational disparity and lack of adequate knowledge among parents were associated with LTF. The most commonly used strategy to overcome LTF suggested by studies was the use of an adequate data management system.

CONCLUSION

This review is a novel attempt to explore the LTF among NHS studies, reasons for LTF and strategies to reduce LTF. This review can act as a basis for planning and execution of effective NHS programs.

Management of unilateral hearing loss

OBJECTIVE

A representative sample of literature regarding unilateral hearing loss (UHL) was reviewed to provide evidence of the effects of UHL and the intervention options available for children with UHL. Considerations during the assessment and management of children with UHL are illustrated using case illustrations.

METHOD

Research articles published from 2013 to 2015 were searched in the PubMed database using the keywords "unilateral hearing loss". Articles from 1950 to 2013 were included from a previous literature review on minimal hearing loss [1]. A retrospective review of charts of 14 children with UHL was also conducted.

RESULTS

The evidence indicates that children with UHL are more likely to have structural anomalies of the inner ear; may face challenges in six different domains, and have six intervention options available. Evidence also indicates that although some children appear to exhibit no delays or difficulties, others have significant challenges, some of which continue into adulthood.

CONCLUSIONS

Children with UHL have to be treated on a case-by-case basis. Parent education regarding UHL, its effects, and all available management options is critical so they can make informed decisions. Close monitoring and good communication between professionals in different domains is crucial in order to minimize the potential negative effects of UHL.

Deaf or hard of hearing children in Saudi Arabia: Status of early intervention services

OBJECTIVE

This study aims to determine the status of early intervention services provided to children who are deaf or hard of hearing and their parents/caregivers from birth to five years of age at two main state hospitals in Riyadh, Saudi Arabia, based on their parents' perceptions.

METHOD

A descriptive quantitative research design was used to determine the status of early intervention services for deaf or hard of hearing children in Saudi Arabia based on their parents' perceptions. Semistructured interviews based on a questionnaire were conducted with 60 research participants from two main state hospitals where early detection and intervention services are provided. A purposive sampling technique was employed. Descriptive and inferential statistical analyses were performed on the data collected.

RESULTS

The participants' children were diagnosed at a substantially late age, resulting in delayed ages for initial hearing aid fitting and enrolment in early intervention services. A significant relationship was found between the residential area of the participants and timely access to intervention services. The results indicated that participants residing in Riyadh were fitted with hearing aids and enrolled into EI services earlier than those living outside of Riyadh. The delivery of information also emerged as a weakness in the EI system for the majority of participants.

CONCLUSION

The findings of the study suggested that limited services of detection and intervention for deaf or hard of hearing children and residential area of participants are likely to be barriers to early access to intervention services. It is proposed that the benefits of UNHS accompanied by appropriate early intervention services should be made available in all regions throughout Saudi Arabia.

Delay in auditory behaviour and preverbal vocalization in infants with unilateral hearing loss

AIM

To evaluate the impact of unilateral hearing loss (UHL) on early aural/oral communication skills of infants by comparing performance to infants with bilateral normal hearing (BNH).

METHOD

Thirty-four infants with UHL (median age 9.4mo, 25th-75th centile 7.34-12.15) and 331 control infants with BNH (median age 9mo, 6.0-13.38) were divided into two subgroups based on risk factors known to cause developmental delay: low risk and high risk. Early auditory skills and preverbal vocalizations were assessed using two parent questionnaires: the Infant-Toddler Meaningful Auditory Integration Scale and the Production of Infants Scale Evaluation.

RESULTS

Of the infants with UHL, 21% showed delays in auditory behaviour and 41% delays in preverbal vocalizations, compared to their peers with BNH (p<0.01). After adjusting for risk level, delayed auditory behaviour and preverbal vocalizations were approximately four and nine times more common in infants with UHL compared to BNH respectively (p<0.01).

INTERPRETATION

This is the first study to show that infants with UHL are at higher risk of delay in early aural/oral communication abilities compared to infants with BNH even in the absence of other known risk factors for developmental delay. This has important implications for early intervention and habilitation of infants with UHL, in order to reduce some of the negative long-term consequences of what was once considered 'minor' hearing loss.

Molecular Etiology of Hereditary Single-Side Deafness: Its Association With Pigmentary Disorders and Waardenburg Syndrome

Unilateral sensorineural hearing loss (USNHL)/single-side deafness (SSD) is a frequently encountered disability in children. The etiology of a substantial portion of USNHL/SSD still remains unknown, and genetic causes have not been clearly elucidated. In this study, the authors evaluated the heritability of USNHL/SSD.The authors sequentially recruited 50 unrelated children with SSD. For an etiologic diagnosis, we performed a rigorous review on the phenotypes of family members of all children and conducted, if necessary, molecular genetic tests including targeted exome sequencing of 129 deafness genes.Among the 50 SSD children cohort, the authors identify 4 (8%) unrelated SSD probands from 4 families (SH136, SB173, SB177, and SB199) with another hearing impaired family members. Notably, all 4 probands in our cohort with a familial history of SSD also have pigmentary abnormalities such as brown freckles or premature gray hair within first degree relatives, which may indicate that genes whose products are involved with pigmentary disorder could be candidates for heritable SSD. Indeed, SH136 and SB199 turned out to segregate a mutation in MITF and PAX3, respectively, leading to a molecular diagnosis of Waardenburg syndrome (WS).We report, for the first time in the literature, a significant heritability of pediatric SSD. There is a strong association between the heritability of USNHL/SSD and the pigmentary abnormality, shedding a new light on the understanding of the molecular basis of heritable USNHL/SSD. In case of children with congenital SSD, it would be mandatory to rigorously screen pigmentary abnormalities. WS should also be included in the differential diagnosis of children with USNHL/SSD, especially in a familial form.

Evaluating a prediction model for infant hearing loss

OBJECTIVES/HYPOTHESIS

The objective of this study was to determine whether a prognostic model using risk factors for hearing loss could predict the chance that infants who failed a newborn hearing screen would subsequently be found to have hearing loss diagnosed by auditory brainstem response testing.

STUDY DESIGN

Individual retrospective case-control study.

METHODS

We studied 229 infants with hearing loss compared with 458 infants with normal hearing. All infants had undergone natural sleep or sedated auditory brainstem response, predominantly for not passing a newborn hearing screen. Risk factors, birth history, and other information were extracted via medical record review. Multiple logistic regression analyses identified independent predictors of hearing loss.

RESULTS

Four risk factors were independently predictive of hearing loss diagnosed by sleep or sedated auditory brainstem response: prematurity, 5-minute APGAR score ≤ 6, intracranial complication, and craniofacial abnormality. A prognostic model developed from these risk factors was associated with a 15% rate of hearing loss in stage I, 52% rate of hearing loss in stage II, and 96% rate of hearing loss in stage III.

CONCLUSIONS

The presence of any one of four independently predictive risk factors in infants who did not pass newborn hearing screen was associated with a 50% rate of hearing loss; having three or more was associated with a 90% rate of hearing loss. Knowing that an infant is at high risk of hearing loss can motivate parents to follow up with diagnostic auditory brainstem response testing so that early identification can lead to early intervention.

Audiologic profile of infants at risk: experience of a Western Sicily tertiary care centre

OBJECTIVE

To identify the incidence of sensorineural hearing loss (SNHL) on infant at risk and to classify the degree and type of hearing loss describing the main causes associated in Western Sicily. To compare single TEOAE and combined TEOAE/ABR techniques studying the referral rate, the false-positive and false-negative rates through concordance test (κ coefficient), sensitivity (TPR) and specificity (TNR) for each protocol.

METHODS

From January 2010 to June 2011, 412 infants at risk, ranging from 4 to 20 weeks of life, transferred to Audiology Department of Palermo from the births centers of Western Sicily, underwent to audiological assessment with TEOAE, tympanometry and ABR. The following risk factors were studied: family history of SNHL, consanguinity, low birth weight, prematurity, cranio-facial abnormality and syndromes associated to SNHL, respiratory distress, intensive care in excess of 5 days (NICU), pregnant maternal diseases, perinatal sepsis or meningitis, hyperbilirubinemia, ototoxic drugs administration.

RESULTS

Forty-seven infants (11.41%) were diagnosed with SNHL; median corrected age at final audiological diagnosis was 12 weeks. SNHL resulted moderate in 44.68%, severe in 10.64% and profound in 21 cases with a significant difference in family history and NICU infants (p<0.0001). As the number of coexisting risk factors increases, the percentage value of SNHL in infants (χ(2)=12.31, p=0.01, r(2)=0.98) and the degree of hearing loss (χ(2)=13.40, p=0.0095, r=0.92) also increase. The study of single TEOAE and combined TEOAE/ABR showed a statistical difference (χ(2)=14.89, p<0.001) with a low concordance value (κ=0.87) confirming the importance of combined techniques for NICU group (κ=0.86) where four cases (0.97%) of auditory neuropathy were diagnosed.

CONCLUSION

This study demonstrates the necessity to implement a neonatal hearing screening program in Western Sicily because of the high percentage of SNHL in infants at risk. Family history of HL is an independent significant risk factor for SNHL easily diagnosed through single TEOAE technique. Combined TEOAE/ABR is the gold standard for NICU babies which are at risk for auditory neuropathy. Coexisting risk factors are an additional risk factor for HL.

Factors influencing follow-up to newborn hearing screening for infants who are hard of hearing

PURPOSE

To document the epidemiological characteristics of a group of children who are hard of hearing, identify individual predictor variables for timely follow-up after a failed newborn hearing screening, and identify barriers to follow-up encountered by families.

METHOD

The authors used an accelerated longitudinal design to investigate outcomes for children who are hard of hearing in a large, multicenter study. The present study involved a subgroup of 193 children with hearing loss who did not pass the newborn hearing screening. The authors used available records to capture ages of confirmation of hearing loss, hearing aid fitting, and entry into early intervention. Linear regression models were used to investigate relationships among individual predictor variables and age at each follow-up benchmark.

RESULTS

Of several predictor variables, only higher levels of maternal education were significantly associated with earlier confirmation of hearing loss and fitting of hearing aids; severity of hearing loss was not. No variables were significantly associated with age of entry into early intervention. Each recommended benchmark was met by a majority of children, but only one third met all of the benchmarks within the recommended time frame.

CONCLUSION

Results suggest that underserved communities need extra support in navigating steps that follow failed newborn hearing screening.

Identifying quality improvement opportunities in a universal newborn hearing screening program

BACKGROUND AND OBJECTIVES

Hospital-based universal newborn hearing screening (UNHS) programs are encouraged to maintain quality assurance protocols, but many hospitals lack the time and resources to initiate this process. We studied a practical approach to measuring baseline quality indicators and identifying improvement opportunities in UNHS programs.

METHODS

We determined screening processes and quality indicators for UNHS programs at 4 hospitals through site visits and a 2-year retrospective review of nursery and audiology records. Nurses, audiologists, and otolaryngologists met for feedback of hospital-specific quality indicators. The sessions identified improvement opportunities and proposed system changes for immediate implementation.

RESULTS

Hospitals screened 21 957 newborns for hearing loss. Screening rates were >99% at all hospitals. Rates of referral and diagnostic testing varied significantly between hospitals. Low referral rates prompted 2 hospitals to adjust screening processes to reduce potential false-negative screening results. Two other hospitals addressed poor diagnostic follow-up by changing the referral process to include additional family contact information. Hospitals also increased referrals to Early Intervention Child Find services on the basis of our finding that these referrals increased the likelihood of diagnostic follow-up fourfold. We could not fully assess indicators of hearing aid eligibility and enrollment in early intervention services due to insufficient documentation.

CONCLUSIONS

Review of nursery and audiology records successfully established most quality indicators for the UNHS programs we studied. Feedback of quality indicators identified multiple improvement opportunities and facilitated endorsement of immediate system changes. This study demonstrates a practical and data-driven approach to quality improvement that can be used by any UNHS program.

Programa de triagem auditiva seletiva em crianças de risco em um serviço de saúde auditiva de São Paulo

OBJETIVO: descrever a população de neonatos encaminhada para um programa de triagem auditiva seletiva, caracterizando e comparando o grupo de lactentes que compareceram à triagem (grupo I) com o grupo de lactentes que não compareceu (grupo II). MÉTODO: a amostra foi constituída por 55 lactentes, provenientes de uma maternidade de São Paulo. A metodologia incluiu a análise de prontuários e entrevistas com as mães. Foram variáveis do estudo: idade da alta hospitalar, resultado da triagem auditiva, resultado do diagnóstico, o tempo entre a alta hospitalar e a triagem, o tempo entre a alta hospitalar e o diagnóstico e, por fim, o tempo entre triagem e diagnóstico. Além destes aspectos, as características socioeconômicas e culturais dos grupos e os indicadores de risco foram analisados. RESULTADOS: foram encaminhados 55 lactentes e o comparecimento à triagem auditiva foi de 76% (42). A média de idade da alta hospitalar foi de 38 dias, da triagem auditiva foi de 42 dias e do diagnóstico foi de 95,1 dias. A média do tempo entre a alta e a triagem foi de 13 dias e da alta e diagnóstico de 40,8 dias. O grupo que compareceu à triagem apresentou peso menor, maior período de internação na UTI, maior número de indicadores de risco, maior renda familiar por pessoa e maior número de consultas pré-natal em comparação aos que não compareceram. CONCLUSÕES: as crianças que mostraram maior adesão à realização da triagem auditiva neonatal seletiva foram aquelas cujas mães compareceram a um maior número de consultas no pré-natal, as que apresentaram maior ocorrência de indicadores de risco, maior tempo de internação e quando as informações na maternidade mostraram-se mais efetivas.

Quality of life in children with unilateral hearing loss: a pilot study

PURPOSE

The objective of this pilot study was to investigate the health-related quality of life (HRQOL) of children with unilateral hearing loss (UHL).

METHOD

The study was conducted in 2 stages among children age 6-17 years. In Stage 1, the authors conducted focus groups of children with UHL and their parents to elicit perceptions of how UHL affected the lives of these children. In Stage 2, a generic pediatric quality of life survey was used to measure HRQOL quantitatively in children with normal hearing, UHL, and bilateral hearing loss. Participants were recruited from the clinical and research populations of an academic otolaryngology department.

RESULTS

The focus groups revealed that the children with UHL experienced barriers due to their hearing loss but learned to adapt. Quantitatively, statistically significant differences between groups were not observed on the 3 main HRQOL scales (Total, Psychosocial, and Physical). Children with UHL had a significantly larger variance on the social functioning score than children with normal hearing and bilateral hearing loss.

CONCLUSIONS

UHL may affect the HRQOL of children; this possibility should be included when counseling parents. However, further research is warranted to determine whether the authors' findings are generalizable to other children with UHL.

Wideband reflectance in newborns: normative regions and relationship to hearing-screening results

OBJECTIVES

To develop normative data for wideband middle-ear reflectance in a newborn hearing-screening population and to compare test performance with 1-kHz tympanometry for prediction of otoacoustic emission (OAE) screening outcome.

DESIGN

Wideband middle-ear reflectance (using both tone and chirp stimuli from 0.2 to 6 kHz), 1-kHz tympanometry, and distortion-product (DP) OAEs were measured in 324 infants at two test sites. Ears were categorized into DP pass and DP refer groups.

RESULTS

Normative reflectance values were defined over various frequency regions for both tone and chirp stimuli in ambient pressure conditions, and for reflectance area indices integrated over various frequency ranges. Receiver operating characteristic analyses showed that reflectance provides the best discriminability of DP status in frequency ranges involving 2 kHz and greater discriminability of DP status than 1-kHz tympanometry. Repeated-measures analyses of variance established that (a) there were significant differences in reflectance as a function of DP status and frequency but not sex or ear; (b) tone and chirp stimulus reflectance values are essentially indistinguishable; and (c) newborns from two geographic sites had similar reflectance patterns above 1 kHz. Birth type and weight did not contribute to differences in reflectance.

CONCLUSIONS

Referrals in OAE-based infant hearing screening were strongly associated with increased wideband reflectance, suggesting middle-ear dysfunction at birth. Reflectance improved significantly during the first 4 days after birth with normalization of middle-ear function. Reflectance scores can be achieved within seconds using the same equipment used for OAE screening. Newborns with high reflectance scores at stage I screening should be rescreened within a few hours to a few days, because most middle-ear problems are transient and resolve spontaneously. If reflectance and OAE are not passed upon stage II screening, referral to an otologist for ear examination is suggested along with diagnostic testing. Newborns with normal reflectance and a refer result for the OAE screen should be referred immediately to an audiologist for diagnostic testing with threshold auditory brainstem response because of higher risk for permanent hearing loss.

Evidence for surviving outer hair cell function in congenitally deaf ears

OBJECTIVES/HYPOTHESIS

The hypotheses of the study were that congenital hearing impairment in infants can result from the isolated loss of inner hair cells of the cochlea and that this is shown by the presence of abnormal positive summating potentials on round window electrocochleography. The objectives were to establish the proportion of infants with hearing loss affected, the nature of the cochlear lesion, and its etiology. And to highlight the important implications for otoacoustic emissions testing and universal neonatal screening.

STUDY DESIGN

A prospectively conducted consecutive cohort study with supplemental review of notes was performed.

METHODS

Four hundred sixty-four children underwent round window electrocochleography and auditory brainstem response testing under general anesthesia to assess suspected hearing loss. The presence of abnormal positive potentials was recorded. Otoacoustic emissions data were collected separately and retrospectively.

RESULTS

Three hundred forty-two children had significant bilateral congenital hearing loss. All results were from hearing-impaired children. Abnormal positive potentials were recorded in 73 of 342 children (21%). Eighty-three percent of children with otoacoustic emissions also had abnormal positive potentials, but only 14% of children without otoacoustic emissions had abnormal positive potentials (P <.001). In the neonatal intensive care unit setting, 43% of infants were found to have abnormal positive potentials, whereas only 10% had abnormal positive potentials if not in the neonatal intensive care unit setting (P <.001). Abnormal positive potentials were present in 63% of infants born before 30 weeks gestation and in 14% of infants born at term (P <.001). Abnormal positive potentials were identified in 57% of infants with documented hypoxia and 11% of children with no episodes (P <.001). Otoacoustic emissions were present in 48% of infants from the neonatal intensive care unit, despite their hearing loss.

CONCLUSION

Both otoacoustic emissions and abnormal positive potentials may originate from outer hair cell activity following inner hair cell loss. This may occur in more than 40% of hearing-impaired children in the neonatal intensive care unit setting. Chronic hypoxia is the most likely cause. Otoacoustic emissions testing may not be a suitable screening tool for such infants.

Changes in transient-evoked otoacoustic emissions in the first month of life

OBJECTIVE

Current Joint Committee on Infant Hearing guidelines recommend the use of transient-evoked otoacoustic emissions (TEOAEs) as a screening tool to identify hearing loss for newborns cared for in the well-baby nursery. Newborns who do not pass the TEOAE screen before leaving the hospital are typically rescreened as outpatients by 1 mo of age, at which time, approximately 50 to 70% pass screening criteria. To better understand why many infants are referred at initial screening but pass at the rescreening, more complete knowledge of developmental differences in the TEOAE levels, noise floor, or a combination of both for infants who pass and fail birth screening is needed. In addition, it has been shown that infants with occluding ear-canal debris are more likely to not pass TEOAE screening at the hospital than those without occluding ear-canal debris. This study explores whether changes in TEOAE levels in half-octave frequency bands are related to changes in ear-canal debris over the first month of life.

DESIGN

Seventy-nine neonates from a well-baby nursery had their hearing screened before leaving the hospital and again at approximately 1 mo of age. All participants passed the follow-up screening. Overall TEOAE levels and levels in half-octave frequency bands centered at 1.5, 2, 3, and 4 kHz were measured. Judgments of ear-canal debris were made by otoscopy and were rated using one of three categories at both visits.

RESULTS

TEOAE levels in infants significantly increased from birth to 1 mo of age across all frequencies tested, regardless of whether they passed or failed the screening at birth. The increase in TEOAE level was frequency dependent, with the greatest increases occurring in the highest frequency bands. No significant correlation between debris change and frequency-specific changes was found for either ear. Infants who failed the screening at birth but who subsequently passed at 1 mo of age had significantly lower TEOAE levels at the rescreening than did infants with passing TEOAE levels at birth. However, pass/fail status at birth was only a weak predictor of TEOAE levels at 1 mo of age.

CONCLUSIONS

The increase in TEOAE levels during the first month of life is frequency dependent, with greater increases occurring at higher frequencies. Increased TEOAE levels were not associated with changes in ear-canal debris.

Neonatal hearing screening model: An Italian regional experience

OBJECTIVE

To produce a model for routine centralized hearing screening including all aspects of the screening, from diagnosis to psychological counseling and early rehabilitation.

METHODS

A prospective observational study on a geographically defined pediatric population (Liguria region, northwestern Italy) and data collection in a data bank. The model proposed was created for the audiological screening of all newborns of the Liguria region. The model includes four phases: (1) preliminary identification of contractual, administrative, legal aspects; (2) screening for identification of congenital hearing impairment; (3) therapy and rehabilitation of identified subjects and genetic analysis; (4) epidemiology, data management, and workload management. To test the feasibility of the model proposed and to establish the workload required according to the resources available in the regional health plan, we performed a pilot study on all infants born in four of the 13 regional birth centers of Liguria region from 1 April 2001 to 30 September 2001.

RESULTS

Out of the 3268 newborns enrolled during the 6-month pilot study, 3238 (99.1%) were screened with otoacoustic emissions (OAE), while screening was refused in 30 newborns (0.9%). OAE resulted in a 'pass' for 3180 newborns (98.2%) and a 'refer' in 58 (1.8%). The standard auditory brainstem response (ABR) test was performed in 156 newborns, 58 of them as a result of the 'refer' at the second OAE and 98 others at audiological risk. Results were positive or uncertain at first ABR in 45 patients. Workload was calculated on the basis of the data obtained in the pilot study to allocate financial and organizational resources.

CONCLUSIONS

The results of the pilot study allowed project planning. We think that the screening model proposed is an example of how a regional organization can deliver improved quality care through a rationalization and optimization process.

Neonatal hearing screening in Albania: Results from an ongoing universal screening program

The paper describes the outcomes of an ongoing universal hearing screening program in Tirana, Albania. The main objectives of the project were the evaluation of the feasibility of a neonatal hearing screening program in Albania, and an evaluation of the prevalence of risk factors in the NICU environment. One thousand five hundred and sixty-one (1561) infants from both the WB and NICU were screened with transient evoked otoacoustic emissions (TEOAE). A detailed history of risk factors was collected in each case, thus it was possible to evaluate the main factors influencing the output of the screening program. It was concluded that the program had the capacity to identify infants with congenital hearing loss provided that an informative component is well-structured and delivered. Also, although the prevalence of risk factors appeared high, the reduction of 'case leakage' would allow the precise estimation of the incidence of hearing loss in the Albanian population.

An implementation study of neonatal hearing screening in the Netherlands

The objective of this study was to investigate whether universal neonatal hearing screening could be integrated in the youth health care program. The screening was performed by nurses of the well baby clinics. A three stage transient evoked otoacoustic emission screening was performed in three different screening settings in order to study the most effective set up regarding participation, refer rates, and costs. In one setting parents visited the well baby clinic, and in two settings babies were screened at home (either in combination with the screening for metabolic diseases or during an intake visit). Screening was performed on 3114 healthy newborns. The setting where universal neonatal hearing screening is integrated with the screening for metabolic diseases, proved to be most efficient and effective. The participation rate of 88.9% was highest in this setting and the overall refer rate (1.4%) was the lowest. The implementation of universal neonatal hearing screening by the well baby clinic nurses was judged to be possible. The results of this study formed the basis for nationwide implementation.

Screening to detect permanent childhood hearing impairment in neonates transferred from the newborn nursery

OBJECTIVES

The focus of this report is hearing screening of newborns transferred from the regular nursery to a specialized area. The purpose of the study undertaken was: (1) to determine whether screening coverage in this population was achieved; (2) to establish whether the linkage between neonatal screening and the diagnostic follow-up was carried out correctly; (3) to better determine the incidence of permanent childhood hearing impairment (PCHI) in this at-risk population.

METHODS

Six population centres averaging 12,000 births annually participated (Bordeaux, Lille, Paris, Marseille, Toulouse and Lyon). Automated auditory brainstem response (AABR) (Natus ALGO 3i) screening was performed in two stages: i.e. infants with initial "positive" results were screened a second time using the same technique. Of the 117,103 babies born during the study period, 4972 neonates were "transferred" and comprised the population for this report (4.2% of the total births).

RESULTS AND DISCUSSION

Screening results for 4972 "transferred" neonates were compared with those of non-transferred neonates (N=112,131). Screening coverage of eligible infants was significantly lower (75.4%) in "transferred" neonates (3750 infants screened) compared to 97.5% coverage of non-transferred neonates (109,349 infants screened). The rate of positive results after the first stage AABR was higher in the "transferred" population (11.1%) than in the non-transferred population (6.5%). Of the 415 "transferred" newborns with initial positive screens, 91.3% were rechecked as stipulated in the project protocol. The second pre-discharge AABR ascertained that in half of the cases auditory function had normalized in the day. Of the 183 "transferred" infants whose result remained suspect at the conclusion of both stages of the neonatal screen (4.9% of the tested population), only 70.5% returned to the audiology centre for diagnostic follow-up. The incidence of bilateral PCHI was markedly higher (4/1000) in "transferred" infants than in the non-transferred population (1.08/1000).

CONCLUSIONS

The difficulty of obtaining universal screening coverage in "transferred" infants was, unfortunately, verified in this prospective, multicentre study. Further, the diversity of our "transferred" population was not much greater than that revealed by careful analysis of published hearing screening studies in neonatal intensive care unit (NICU) infants. The influence of risk factors and their more or less complex combinations is apparent.

Newborn hearing screening: an outpatient model

OBJECTIVE

The purpose of this study was to assess the feasibility of implementing an outpatient model of a newborn hearing screening program with a particular focus on determining how compliance with the follow-up appointment related to specific socio-economic and demographic factors associated with the mother.

METHOD

Mothers who delivered their babies in public hospitals in Recife, northeast Brazil, were invited to participate in a two-step program. In Step 1 they were interviewed with regard to specific socio-economic and demographic factors, and then scheduled for a hearing screening test for their baby 1 month after discharge. In Step 2, the baby's hearing was screened using transient otoacoustic emissions.

RESULTS

A total of 1035 mothers consented to participate in Step 1, but only 149 returned to participate in Step 2 (14.3%). Analysis of the socio-economic and demographic factors indicated that mothers who did not comply with the scheduled newborn hearing screening (NHS) test generally had less than a high school education and came from primarily lower income families who lived in rural areas outside of Recife.

CONCLUSION

The results of this study highlight some socio-economic and demographic factors of the population of northeast Brazil that contribute to a low compliance rate for an outpatient model of a newborn hearing screening program. Possible solutions to the low compliance rate are considered.

Newborn hearing screening follow-up: factors affecting hearing aid fitting by 6 months of age

PURPOSE

To determine the extent to which the goal of hearing aid fitting by 6 months of age is being achieved and to identify barriers to achieving that goal.

METHOD

Screening and follow-up records from 114,121 infants born at 6 hospitals were collected over a 6-year period. Infants diagnosed with permanent hearing loss requiring amplification were categorized as fit on time, fit late, or lost to follow-up. Seven factors were empirically identified as potential barriers to timely intervention.

RESULTS

Ninety-one percent of referred infants returned for follow-up evaluation. Hearing aids were fit on 107 of the 192 infants requiring amplification. Thirty-nine percent were fit on time, and 61% were fit late or lost to follow-up. Unilateral hearing loss and late diagnosis were statistically significant (p < .0001) predictors for late fitting and loss to follow-up. Conductive hearing loss and coverage by Medicaid were also statistically significant (p < .0001) predictors for loss to follow-up.

CONCLUSION

High return rate for follow-up does not ensure hearing aid fitting by 6 months of age. Infants with unilateral hearing loss are at particular risk of being lost to follow-up.

Hearing loss in children with very low birth weight: current review of epidemiology and pathophysiology

An association between birth weight <1500 g (very low birth weight (VLBW)) and hearing loss has been long recognised. As universal hearing screening programmes have become widely implemented and the survival rate of VLBW babies in modern intensive care units has increased, we have gained a substantially better understanding of the nature of this problem. However, many gaps in our knowledge base exist. This review describes recent data on hearing loss in the VLBW population and explains the current level of understanding about the physiological basis underlying the auditory deficits in these patients. Although VLBW alone may not have a severe impact on hearing, it is commonly associated with multiple other risk factors that can alter hearing in a synergistic fashion. Therefore, the risk of hearing loss is substantially higher than in the general newborn population. Also, it is important to perform a more comprehensive audiometric evaluation than standard otoacoustic emission screening for infants who are in the neonatal intensive care unit in order not to miss hearing loss due to retrocochlear pathology. Furthermore, children with VLBW are also at increased risk of experiencing progressive or delayed-onset hearing loss, and thus should continue to have serial hearing evaluations after discharge from the neonatal intensive care unit.

Preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns

OBJECTIVES

Our goals were to (1) study the prevalence of hearing impairment in a large cohort of infants with preauricular skin tags or ear pits and compare it with that among all other newborns participating in our universal newborn hearing screening program during the same period and (2) evaluate the effectiveness of transient evoked otoacoustic emissions as a hearing-screening tool in this population.

PATIENTS AND METHODS

During the study period of 7.5 years, 68484 infants were screened for hearing impairment, of whom 637 (0.93%) had preauricular skin tags and/or ear pits. The population was divided into 3 groups: (1) a low-risk group for hearing impairment; (2) a high-risk group for hearing impairment; and (3) a very high-risk group for hearing impairment. The screening results and audiological follow-up for these infants were examined retrospectively.

RESULTS

A significantly higher prevalence of permanent hearing impairment was found among infants with preauricular skin tags or ear pits (8 of 1000), compared with infants without tags or pits (1.5 of 1000). In the low-risk group, the prevalence was 3.4 of 1000, compared with 0.5 of 1000 in infants with and without preauricular tags or pits, respectively. In the high-risk group, the prevalence was 77 of 1000, compared with 20 of 1000 in infants with and without preauricular tags or pits, respectively. The odds ratio for hearing impairment associated with preauricular skin tags and/or ear pits after adjusting for level of risk group was 4.9. All infants diagnosed with permanent hearing impairment, with the exception of 1 with late-onset impairment, were detected by in-hospital transient-evoked otoacoustic emissions screening.

CONCLUSIONS

Infants with preauricular skin tags or ear pits are at increased risk for permanent hearing impairment. Transient-evoked otoacoustic emissions were found to be an effective hearing-screening tool in this population.

Early language outcomes of early-identified infants with permanent hearing loss at 12 to 16 months of age

OBJECTIVES

The objectives of this study were to determine the early language outcomes of children with mild to profound hearing loss, compared with hearing control children, at 12 to 16 months of age and to examine the effects of "very early" enrollment (</=3 months) in early intervention.

METHODS

This was a prospective longitudinal study of the outcomes of a cohort of 30 infants identified in the Rhode Island universal newborn hearing screening program and 96 hearing control subjects. Eligible families with children with all degrees of congenital hearing loss were invited to enroll. Child language skills were assessed by using the MacArthur-Bates Communicative Development Inventory, Words and Gestures, at 12 to 16 months.

RESULTS

Children with moderate/profound hearing loss had significantly lower numbers of phrases understood, words understood, and early, later, and total gestures, compared with children with mild/minimal hearing loss and hearing control subjects. Furthermore, children with hearing loss who were enrolled in early intervention at </=3 months had significantly higher percentile scores for number of words understood, words produced, and early, later, and total gestures, compared with those enrolled at >3 months. Regression analyses to test the independent effects on language skills of children with hearing loss identified enrollment in early intervention at </=3 months as an independent predictor of percentile scores for word and early gesture production.

CONCLUSIONS

Very early enrollment (</=3 months) in early intervention has beneficial effects on early language for children with hearing loss. Nevertheless, 12- to 16-month-old children with moderate/profound hearing loss exhibit delayed receptive and expressive language skills in oral and signed English modes, compared with peers with either mild/minimal hearing loss or typical hearing sensitivity.

Ligurian experience on neonatal hearing screening: clinical and epidemiological aspects

AIM

Early identification and rehabilitation of newborns with congenital hearing impairment (HI) by Universal Neonatal Hearing Screening (UNHS).

METHODS

The neonatal population was divided into two groups: babies with No Audiological Risk (NAR), and babies With Audiological Risk (WAR). NAR neonates underwent OAE testing, and in case of a doubtful (Refer) result, ABR testing was carried out. All WAR newborns underwent ABR testing within the third month of life.

RESULTS

Between February 1, 2002 and December 31, 2004, UNHS was carried out on 32 502 newborns at the 13 regional birth centres, representing 98.7% of the whole regional neonatal population. The prevalence of HI in the population we tested was estimated at about 1 per thousand, while Bilateral Hearing Impairment (BHI) was estimated at 0.65 per thousand. A 3.7% prevalence of HI and a 2.8% prevalence of BHI was observed among the WAR population. Median age at the end of the diagnostic procedures was 6.7 months in the WAR population and 6.9 months in the NAR population.

CONCLUSIONS

Our project is based on two levels of testing, which resulted in a 0.28% false-positive rate with 100% sensitivity and 99% specificity. Our screening is the first Italian experience that has been extended to a whole region and the results prove that regional neonatal hearing screening is feasible.

Test-Retest Reliability of Wideband Reflectance Measures in Infants under Screening and Diagnostic Test Conditions

OBJECTIVE

The main goal of this study was to examine the test-retest reliability of wideband reflectance (WBR) measures collected from infants in screening and diagnostic hearing test environments. In addition, the results of WBR testing for infants who passed and failed otoacoustic emission (OAE) screening were examined to determine whether these measures distinguished between the two groups.

DESIGN

Repeated WBR measures were collected from two groups of infants, one group tested in an outpatient hearing screening setting and the other group in a diagnostic test setting. For a total of 127 infants and a control group of 10 adults, repeated WBR measurements were made with the probe left in place between the two tests (T1 and T2) and after reinsertion of the probe (T3) for a total of 3 measurements. Test-retest differences were calculated for each individual across one-third octave frequency bands, and the mean and 90th percentile were calculated by subject group and OAE results. WBR patterns were also compared between infants who passed versus failed OAE screening.

RESULTS

Mean test-retest differences were smaller for the diagnostic group than for the screening group. Test-retest differences were largest for the reinsertion condition and for the frequencies below 500 Hz. While the low frequencies were variable, the test-retest differences were smallest in the mid-frequency range which is thought to be the frequency range most sensitive to middle ear dysfunction. Test-retest performance did not differ between infants who passed or failed OAE screening. However, infants who failed OAE screening had significantly higher WBR in the range from 630 to 2000 Hz than infants who passed OAE screening.

CONCLUSIONS

Test-retest performance was poor for frequencies below 500 Hz, but in general test-retest differences were small across the important mid-frequency range. Reinsertion of the probe between repeated tests yielded larger and more variable test-retest differences. Careful monitoring of probe fit and testing while infants are in a quiet state appears to be critical for obtaining reliable WBR results. Analysis of WBR results indicated significantly higher reflected energy in the mid-frequency range for infants who failed OAE screening than for those who passed OAE screening. Although conclusions are limited by the fact that the true status of the middle ear and cochlea were not known for the infants in this study, this result may indicate that a number of these infants failed OAE screening due to transient or permanent middle ear dysfunction which was detected by WBR.

A multisite study to examine the efficacy of the otoacoustic emission/automated auditory brainstem response newborn hearing screening protocol: introduction and overview of the study

PURPOSE

This article is the 1st in a series of 4 articles on a recently completed multistate study of newborn hearing screening.

METHOD

The study examined the efficacy of the 2-stage otoacoustic emission/automated auditory brainstem response (OAE/A-ABR) protocol for identifying hearing loss in newborns.

RESULTS

The study found that the 2-stage OAE/A-ABR protocol did miss a significant number of babies who exhibited a permanent hearing loss by 1 year of age. Three subsequent articles will describe the research design and results in detail, discuss the behavioral assessment of infants, and summarize the implications of the study for policy, practice, and research.

Improvement of return rates in a Neonatal Hearing Screening Program: the contribution of social work

This paper aims to describe the implementation of a Neonatal Hearing Screening Program in a school hospital, focusing on the return rates among infants who failed the first screening. The population who goes to the school hospital for health services comes mainly from economically underprivileged groups. Even though our previous return rates were comparable to those reported elsewhere, we felt it was important to improve the methodology of the screening process in order to try and obtain better results. Our hypothesis was that scarce knowledge on early hearing loss detection and on the benefits of early intervention could be reasons for mothers to give less importance to the second screening. So, a strategy was developed around the idea of providing very detailed information to the mothers about the screening process since preliminary data, gathered with a different group of in-patients, had shown that mothers possessed little knowledge about neonatal hearing screening and the consequences of hearing loss for children's development. The no-return rates decreased considerably (from 39.8% to 25.8%). The findings of this research showed both the need of an adequate way of imparting information to the mothers of newborns about hearing screening in economically underprivileged populations, and the role of social work in this process. Without adequate knowledge on hearing screening and the consequences of hearing loss, a high percentage of newborns may not take advantage of free universal hearing screening programs.

Initial Audiologic Assessment of Infants Referred From Well Baby, Special Care, and Neonatal Intensive Care Unit Nurseries

Purpose

The purpose of the study was to evaluate the effectiveness of a 2-hr initial audiologic assessment appointment for infants referred from area universal newborn hearing screening (UNHS) programs to a clinical audiology department in an urban hospital.

Method

A prospective auditory brainstem response (ABR)-based protocol, including clicks, frequency-specific tone bursts, and bone-conducted stimuli, was administered by 10 audiologists to 375 infants. Depending on the ABR findings, additional test options included distortion product otoacoustic emissions (DPOAEs), high-frequency tympanometry, and/or otologic examination.

Results

In 88% of the 2-hr test sessions, at least 4 ABR threshold estimates were obtained (i.e., bilateral clicks and either a 500- or 1000-Hz tone burst and a 4000-Hz frequency tone burst for the better ear). The incidence of hearing loss was significantly different across nursery levels: 18% for Level I (well baby), 29% for Level II (special care), and 52% for Level III (neonatal intensive care unit). Hearing loss type was defined at the initial assessment for 35 of the 51 infants with bilateral hearing loss based on bone-conduction ABR, latency measures, DPOAEs, high-frequency tympanometry, and/or otologic examination.

Conclusions

Our findings indicate that a 2-hr test appointment is appropriate for all nursery levels to diagnose severity and type of hearing loss in the majority of infants referred from UNHS. Examination by an otolaryngologist within 24–48 hr further defines the hearing loss and facilitates treatment plans.