Effectiveness and Efficiency of a Universal Newborn Hearing Screening in Germany

Role of Newborn Hearing Screening Done Over One Year in a Tertiary Care Hospital: A Cross-Sectional Study

BACKGROUND

Newborn hearing screening (NHS) is universally acknowledged as a critical early intervention to prevent adverse developmental outcomes caused by undetected hearing loss. Despite its proven benefits, the implementation of NHS varies, especially in tertiary care hospitals that manage high-risk neonates. This study investigates the effectiveness and implementation of NHS protocols in these settings.

METHODOLOGY

This cross-sectional study was conducted in the Department of Neonatology at Saveetha Medical College, Chennai. All newborns delivered between January 2023 and December 2023 were included. Screening involved initial otoacoustic emissions (OAEs) tests, automated auditory brainstem response (AABR) followed by brainstem evoked response audiometry (BERA) for those who failed. Data on demographic characteristics, screening results, and follow-up compliance were collected and analyzed.

RESULTS

A total of 1,398 neonates were screened. Initial screening resulted in 416 (29.7%) referrals. Follow-up screenings showed high compliance rates, with significant detections of hearing impairments through BERA. The screening was completed for 1,341 babies. Fifty-five babies were lost to follow-up. Of these, 2 babies (0.1%) with a high risk for hearing loss were diagnosed with bilateral severe hearing loss. The study also noted demographic factors such as kinship and obstetric history that might influence hearing loss risks.

CONCLUSIONS

NHS plays a vital role in the early detection and management of hearing impairments, which is crucial for preventing negative impacts on a child's development. This study advocates for the systematic implementation of NHS protocols in all tertiary care hospitals, especially those serving high-risk neonates, to ensure optimal developmental outcomes.

[Newborn hearing screening in Germany-results of the 2011/2012 and 2017/2018 evaluations]

BACKGROUND

Newborn hearing screening (NHS) was introduced nationwide by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G‑BA) in 2009. In this process, quality targets were also set in the pediatrics directive. In order to review the quality NHS in Germany, the G‑BA commissioned a consortium to conduct an initial evaluation for the years 2011 and 2012 and a follow-up evaluation for 2017 and 2018.

METHODS

The evaluations were based on NHS screening parameters (Sammelstatistiken) that must be documented by all obstetrics and neonatology departments as NHS providers and can also be compiled through cooperation with hearing screening centers (HSCs). Additional data were collected through questionnaires and interviews and routine data were used to evaluate the screening process.

RESULTS

In 13 federal states, a total of 15 HSCs are involved in the screening process. Across Germany, an NHS screening rate of 86.1% was documented in 2018 (82.4% in 2012), but this differed significantly between the federal states. The specified quality targets could not yet be implemented everywhere. For example, only less than half of the obstetric departments achieved the specified screening rate of over 95%. A comparison of data from the follow-up evaluation and the first evaluation showed that the structural quality of NHS had improved, while the process quality remained the same or had deteriorated. The refer rate (children who were discharged without passing the screening) increased from 5.3% to 6.0%.

DISCUSSION

To improve the quality of NHS, HSCs should be established nationwide and a second screening should be carried out more consistently before discharge in the case of a refer result in the initial screening.

Availability of data for cost-effectiveness comparison of child vision and hearing screening programmes

OBJECTIVE

For cost-effectiveness comparison of child vision and hearing screening programmes, methods and data should be available. We assessed the current state of data collection and its availability in Europe.

METHODS

The EUSCREEN Questionnaire, conducted in 2017-2018, assessed paediatric vision and hearing screening programmes in 45 countries in Europe. For the current study, its items on data collection, monitoring and evaluation, and six of eleven items essential for cost-effectiveness analysis: prevalence, sensitivity, specificity, coverage, attendance and loss to follow-up, were reappraised with an additional questionnaire.

RESULTS

The practice of data collection in vision screening was reported in 36% (N = 42) of countries and in hearing screening in 81% (N = 43); collected data were published in 12% and 35%, respectively. Procedures for quality assurance in vision screening were reported in 19% and in hearing screening in 26%, research of screening effectiveness in 43% and 47%, whereas cost-effectiveness analysis was performed in 12% for both. Data on prevalence of amblyopia were reported in 40% and of hearing loss in 77%, on sensitivity of screening tests in 17% and 14%, on their specificity in 19% and 21%, on coverage of screening in 40% and 84%, on attendance in 21% and 37%, and on loss to follow-up in 12% and 40%, respectively.

CONCLUSIONS

Data collection is insufficient in hearing screening and even more so in vision screening: data essential for cost-effectiveness comparison could not be reported from most countries. When collection takes place, this is mostly at a local level for quality assurance or accountability, and data are often not accessible. The resulting inability to compare cost-effectiveness among screening programmes perpetuates their diversity and inefficiency.

Prevalence of Hearing Loss in Dutch Newborns; Results of the Nationwide Well-Baby Newborn Hearing Screening Program

Background: Few studies report prevalence rates of hearing loss in newborns for nationwide populations. The Dutch well-baby newborn hearing screening covers almost all eligible children and has high participation rates for follow-up screening rounds and diagnosis. This allows calculating reliable prevalence rates of permanent neonatal hearing loss specified by severity. Methods: Results from the well-baby newborn hearing screening program and diagnostic follow-up of referred children from 2015 to 2019 were included in calculating prevalence rates. Hearing loss was classified according to the degree of severity. Results: A total of 99.7% of 833,318 children eligible for screening were included. A total of 0.3% were referred for audiological diagnostics. Permanent bilateral hearing loss of ≥40 dB was diagnosed in 23.7% of them and unilateral hearing loss in 14.4%. A prevalence rate of 1.23 per 1000 children was found, 0.46 for unilateral hearing loss and 0.76 for bilateral hearing loss. Moderate hearing loss is most common in children with bilateral hearing loss (0.47), followed by profound (0.21) and severe (0.06) hearing loss. In children with unilateral hearing loss, prevalence rates are the highest for profound hearing loss (0.21), followed by moderate (0.16) and severe (0.09) hearing loss. A total of 87.5% of the children were diagnosed within the age of 3 months. Conclusions: Because of the high quality of the Dutch well-baby hearing screening program, reported results approximate true prevalence rates of permanent hearing loss by severity.

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).

Language-Independent Hearing Screening - Increasing the Feasibility of a Hearing Screening Self-Test at School-Entry

A tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check (SEC), was adapted to make it feasible for young children. Two experiments were conducted. The first experiment investigated the SEC's feasibility, as well as its sensitivity and specificity for detecting childhood hearing loss with a monaural adaptive test procedure. In the second experiment, the SEC sounds, noise, and test format were adapted based on the findings of the first experiment. The adaptations were combined with three test procedures, one similar to the one used in Experiment 1, one presenting the sounds dichotically in diotic noise, and one presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule. Results in young children show high sensitivity and specificity to detect different grades of conductive and sensorineural hearing loss (70-90%). When using an adaptive, monaural procedure, the test duration was approximately 6 min, and 17% of the results obtained were unreliable. Adaptive staircase analyses showed that the unreliable results probably occur due to attention/motivation loss. The test duration could be reduced to 3-4 min with adapted test formats without decreasing the test-retest reliability. The unreliable test results could be reduced from 17% to as low as 5%. However, dichotic presentation requires longer training, reducing the dichotic test format's feasibility.

Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study

BACKGROUND

To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium.

METHODS

We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario.

FINDINGS

Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested.

INTERPRETATION

This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services.

FUNDING

None.

[Evaluation of a Screening Program: Challenges of Data Collection Using the Example of the Newborn Hearing Screening]

BACKGROUND

The aim of the newborn hearing screening (NHS) is to identify and treat children with bilateral hearing disorders early. The NHS is regulated in Germany by the Pediatric Directive, which recommends an evaluation after 5 years. This evaluation was performed for the first time nationwide for children born between 2011 and 2012 regarding structural, process and result quality.

OBJECTIVES

Challenges in the collection of appropriate data as basis for evaluation are described and possible improvements are suggested.

METHODS

All maternity and neonatology wards performing the NHS were identified and their documentations of the NHS analysed. In addition, all pediatric audiologists were identified to gather data on children with bilateral permanent congenital hearing disorder.

RESULTS

The identification of relevant maternity and neonatology wards was very burdensome. More than half of them were not aware that NHS had to be documented. There was no documentation on more than 15% of the children that were to be screened. Furthermore, data concerning bilateral congenital hearing disorders was only accessible for 60% of the expected number of affected children.

CONCLUSIONS

Data required for the evaluation of the NHS regarding structural, process and result quality were incomplete and missing. The database for evaluations should be defined precisely and structures needed to obtain meaningful results have to be established in advance. Nevertheless, the evaluation of the NHS provides meaningful results concerning the screening process in Germany.

Implementation of a neonatal hearing screening programme in three provinces in Albania

OBJECTIVES

The EUSCREEN study compares the cost-effectiveness of paediatric hearing screening programmes and aims to develop a cost-effectiveness model for this purpose. Alongside and informed by the development of the model, neonatal hearing screening (NHS) is implemented in Albania. We report on the first year.

METHODS

An implementation plan was made addressing objectives, target population, screening protocol, screener training, screening devices, care pathways and follow up. NHS started January 1st, 2018 in four maternity hospitals: two in Tirana, one in Pogradec and one in Kukës, representing both urban and rural areas. OAE-OAE-aABR was used to screen well infants in maternity hospitals, whereas aABR-aABR was used in neonatal intensive care units and in mountainous Kukës for all infants. Screeners' uptake and attitudes towards screening and quality of screening were assessed by distributing questionnaires and visiting the maternity hospitals. The result of screening, diagnostics, follow up and entry into early intervention were registered in a database and monitored.

RESULTS

Screeners were keen to improve their skills in screening and considered NHS valuable for Albanian health care. The number of "fail" outcomes after the first screen was high initially but decreased to less than 10% after eight months. In 2018, 11,507 infants were born in the four participating maternity hospitals, 10,925 (94.9%) of whom were screened in the first step. For 486 infants the result of screening was not registered. For the first screen, ten parents declined, eight infants died and one infant was discharged before screening could be performed. In 1115 (10.2%) infants the test either could not be performed or the threshold was not reached; 361 (32,4%) of these did not attend the second screen. For the third screen 31 (34.4%) out of 90 did not attend. Reasons given were: parents declined (124), lived too far from screening location (95), their infant died (11), had other health issues (7), or was screened in private clinic (17), no reason given (138).

CONCLUSIONS

Implementation of NHS in Albania is feasible despite continuing challenges. Acceptance was high for the first screen. However, 32.4% of 1115 infants did not attend the second screen, after a "fail" outcome for the first test.

Newborn and Infant Hearing Screening Facing Globally Growing Numbers of People Suffering from Disabling Hearing Loss

Recent prevalence estimates indicate that in 2015 almost half a billion people-about 6.8% of the world's population-had disabling hearing loss and that prevalence numbers will further increase. The World Health Organization (WHO) currently estimates that at least 34 million children under the age of 15 have disabling hearing loss. Based on a 2012 WHO report, approximately 7.5 million of these children were under the age of 5 years. This review article focuses on the importance of high-quality newborn and infant hearing screening (NIHS) programs as one strategy to ameliorate disabling hearing loss as a global health problem. Two WHO resolutions regarding the prevention of deafness and hearing loss have been adopted urging member states to implement screening programs for early identification of ear diseases and hearing loss in babies and young children. The effectiveness of these programs depends on factors such as governmental mandates and guidance; presence of a national committee with involvement of professionals, industries, and stakeholders; central oversight of hearing screening; clear definition of target parameters; presence of tracking systems with bi-directional data transfer from screening devices to screening centers; accessibility of pediatric audiological services and rehabilitation programs; using telemedicine where connectivity is available; and the opportunity for case discussions in professional excellence circles with boards of experts. There is a lack of such programs in middle- and low-income countries, but even in high-income countries there is potential for improvement. Facing the still growing burden of disabling hearing loss around the world, there is a need to invest in national, high-quality NIHS programs.

[Global action for hearing loss]

Over 6% of the world's population lives with disabling hearing loss which can adversely affect their development, education and overall health. Unless action is taken, it is expected that by 2050 the prevalence of hearing loss could grow to nearly 10%. Many of the causes responsible for this growth, such as noise, ototoxicity and ear infections are preventable through public health measures. In those who develop hearing loss: appropriate, timely and cost effective interventions can reduce its adverse impact. However, most people do not have access to the required ear and hearing care services. Strong government-led action, is required to address this issue. Such action must focus on raising awareness in all sections of society and providing services to address hearing loss. Professional groups and civil society has to support governments in developing and implementing evidence-based policies that can ensure accessible ear and hearing care for all.

Newborn Hearing Screening in Bavaria-Is It Possible to Reach the Quality Parameters?

Since the 1 January, 2009, newborn hearing screening (NHS) has been obligatory for every child in Germany. NHS is part of the Pediatrics Directive of the Federal Joint Committee. In this directive, details of the procedures and screening quality to be achieved are given. We evaluate if these quality criteria were met in Bavaria in 2016. The NHS data of children born in 2016 in Bavaria were evaluated for quality criteria, such as screening coverage in screening facilities, screening methods, referral rate (rate of failed tests at discharge) and a child's age at the diagnosis of a hearing disorder. NHS was documented for 116,776 children born in Bavaria in 2016. In the first step, 78,904 newborns were screened with transient evoked otoacoustic emissions and 37,865 with automated auditory brainstem response. Of these, 9182 (7.8%) failed the first test in one or both ears. A second screening before discharge was performed on 53.3% of the newborns with a refer result in the first test, out of which 58.7% received a pass result. After the screening process, 4.6% of the newborns were discharged with a refer result. Only 18% of the first controls after discharge were performed by a pediatric audiologist. In 37.9% of the newborns, the screening center intervened to assure the control of any failed screening test. The median age of diagnosis for bilateral hearing loss was 5.3 months. In Bavaria, NHS was implemented successfully. A tracking system for all children who failed the hearing screening test is pivotal for early diagnosis and therapy of children with hearing deficiency.

Population-based cross-sectional study to assess newborn hearing screening program in central Germany

OBJECTIVES

Early diagnosis of congenital hearing loss is fundamental to minimize the negative consequences on the speech development. To lower the age at diagnosis and at intervention in hearing impaired children, not only universal newborn hearing screening (NHS) but also tracking is considered essential. The aim of the study was to evaluate the first six years after implementation of the population based newborn hearing screening program in Saxony-Anhalt, one German Federal State.

METHODS

The cross-sectional cohort study consisted of three cohort samples. Overall 102,301 infants born between January 2010 and December 2015 were included. NHS protocol was developed as dual target group protocol with two sub-protocols. The screening technique included Transient Evoked Otoacoustic Emissions (TEOAE) and Automated Auditory Brainstem Response (AABR) test. Newborns were assigned to the sub-protocols according to their audiological risk factors. Additionally, to evaluate the quality of NHS and tracking (false-negative screening) we were analysing data from a cohort of hearing impaired children diagnosed up to the age of three years. We calculated quality indicators and compared them with international guidelines.

RESULTS

101,102 (98.8%) infants were screened. The prevalence of bilateral neonatal hearing loss was 2.32 per 1000 newborns. The median age was two days at first screening, three month at diagnostic testing, and four month at intervention onset. 2.6% infants were lost to follow-up. 56.3% had a final diagnosis of bilateral sensorineural hearing loss. The sensitivity of 0.85 (KI 95%: 0.76–0.91) and a specificity of 0.84 (KI 95%: 0.84–0.85) was calculated for the NHS program.

CONCLUSIONS

The analysis of benchmarks and outcomes of NHS demonstrated that the program reaches its main goal to identify the hearing impaired newborns in a timely manner.

Acquisition of who-question comprehension in German children with hearing loss

For children with sensorineural hearing loss the ability to understand wh-questions might be particularly challenging because they often have only restricted access to spoken language input during optimal periods of language acquisition. In previous research it has been suggested that this restricted input during critical stages in language acquisition might lead to syntactic deficits that persist into adolescence. In this study we want to pursue this issue by investigating the comprehension of wh-questions in German children with bilateral sensorineural hearing loss. We report results of a who-question comprehension task in a group of 21 3- to 4-year-old German hard-of-hearing children compared to a group of age-matched children with normal hearing. The group data and individual performance patterns suggest that the syntactic comprehension difficulties observed in some, but not all, of the children with hearing loss reflect a delay in the acquisition of who-question comprehension rather than a persistent syntactic deficit. Follow-up data elicited from a subgroup of children confirm this supposition.

Inventory of current EU paediatric vision and hearing screening programmes

OBJECTIVE

To examine the diversity in paediatric vision and hearing screening programmes in Europe.

METHODS

Themes for comparison of screening programmes derived from literature were used to compile three questionnaires on vision, hearing, and public health screening. Tests used, professions involved, age, and frequency of testing seem to influence sensitivity, specificity, and costs most. Questionnaires were sent to ophthalmologists, orthoptists, otolaryngologists, and audiologists involved in paediatric screening in all EU full-member, candidate, and associate states. Answers were cross-checked.

RESULTS

Thirty-nine countries participated; 35 have a vision screening programme, 33 a nation-wide neonatal hearing screening programme. Visual acuity (VA) is measured in 35 countries, in 71% of these more than once. First measurement of VA varies from three to seven years of age, but is usually before age five. At age three and four, picture charts, including Lea Hyvarinen, are used most; in children over four, Tumbling-E and Snellen. As first hearing screening test, otoacoustic emission is used most in healthy neonates, and auditory brainstem response in premature newborns. The majority of hearing testing programmes are staged; children are referred after 1-4 abnormal tests. Vision screening is performed mostly by paediatricians, ophthalmologists, or nurses. Funding is mostly by health insurance or state. Coverage was reported as >95% in half of countries, but reporting was often not first-hand.

CONCLUSION

Largest differences were found in VA charts used (12), professions involved in vision screening (10), number of hearing screening tests before referral (1-4), and funding sources (8).

Hearing impairment and language delay in infants: Diagnostics and genetics

This overview study provides information on important phoniatric and audiological aspects of early childhood hearing and language development with the aim of presenting diagnostic and therapeutic approaches. The article first addresses the universal newborn hearing screening that has been implemented in Germany for all infants since January 2009. The process of newborn hearing screening from the maternity ward to confirmation diagnostics is presented in accordance with a decision by the Federal Joint Committee (G-BA). The second topic is pediatric audiology diagnostics. Following confirmation of a permanent early childhood hearing disorder, the search for the cause plays an important role. Hereditary hearing disorders and intrauterine cytomegalovirus (CMV) infection, probably the most common cause of an acquired hearing disorder, are discussed and compared with the most common temporary hearing disorder, otitis media with effusion, which in some cases is severe enough to be relevant for hearing and language development and therefore requires treatment. The third topic covered in this article is speech and language development in the first 3 years of life, which is known today to be crucial for later language development and learning to read and write. There is a short overview and introduction to modern terminology, followed by the abnormalities and diagnostics of early speech and language development. Only some aspects of early hearing and language development are addressed here. Important areas such as the indication for a cochlear implant in the first year of life or because of unilateral deafness are not included due to their complexity.

Main outcomes of a newborn hearing screening program in Belgium over six years

OBJECTIVE

To present the outcomes of the newborn hearing screening program in Belgium (French-speaking area) since its implementation and to analyze its evolution between 2007 and 2012 in the neonatal population without reported risk factors for hearing loss.

METHODS

The study was descriptive and based on a retrospective analysis of six annual databases (2007-2012) from the newborn hearing screening program. The main outcomes were identified: prevalence of reported hearing impairment; coverage rates (first and second test, follow-up); proportions of conclusive screening tests; referral rate. Each outcome was presented for the six years and by year of birth. Chi-squares were used to study differences in the various outcomes according to time.

RESULTS

Over the six years, 264,508 newborns were considered as eligible for the screening. Hearing impairment was confirmed in 1.41‰ (n = 374) of them, with significant disparities from year to year, between 0.67‰ and 1.94‰. Analysis of the screening process showed that only 92.71% (n = 245,219) of the eligible newborns underwent a first hearing test. This coverage rate varied greatly over time: at the beginning, less than 90% of the newborns had a first test and it rose to almost 95%. After the two screening steps, 2.40% (n = 6340) of the newborns were referred to an ENT doctor; the referral rate slightly decreased during the first years of the program and then stabilized around 2.4%. Over the period, only 62.21% of the referred newborns had a follow-up; the follow-up rate was particularly low for the first year (44.91%) and then strongly increased (+19.52% in 2008) but never exceeded 70%.

CONCLUSIONS

Outcome measures for the newborn hearing screening program in Belgium are lower than the benchmarks released by the Joint Committee on Infant Hearing. Nevertheless, the evolution of the outcome measures since the implementation of the program has been positive, particularly during the first years. At some point, most of the outcome measures decreased or at least did not change any further. The motivation and commitment of the professionals have to be supported in a variety of ways to improve outcome measures and thus, the quality of the program.

[Universal newborn hearing screening : Definition of uniform parameters by the Association of German Hearing Screening Centers as a requirement for nationwide evaluation with valid results]

BACKGROUND

Since 2009, all newborns in Germany have been entitled to universal neonatal hearing screening (UNHS). UNHS with tracking of test results leads to earlier detection of hearing disorders. The Association of German Hearing Screening Centers (Verband Deutscher Hörscreening-Zentralen, VDHZ) was founded to promote nationwide tracking, validity and quality control of UNHS results.

OBJECTIVES

A comparable data structure in the different screening centers, with uniform definitions of primary parameters is essential for the nationwide evaluation of UNHS results. To address the question of whether a data structure with comparable definitions already exists or still has to be created, the existing structures and primary parameter definitions in the hearing screening centers should be investigated and compared.

METHODS

A survey was conducted in all hearing screening centers to assess how data on the primary UNHS parameters defined in pediatric guidelines was gathered. In the case of discrepancies, uniform definitions were created. Finally, the practicability of these definitions was evaluated.

RESULTS

Due to differing definitions of primary parameters, some of the data were not comparable between the individual centers. Therefore, uniform definitions were created in a consensus process. In the centers, the screening method, the two-step first screening and the result of the first screening now correspond to these uniform definitions. Other parameters, e.g. the total number of newborns, still vary widely, rendering the comparison of screening rates almost impossible.

CONCLUSION

Valid evaluation of UNHS not only requires nationwide establishment of hearing screening centers, but also unified data structures and parameter definitions.

[Quality of universal newborn hearing screening results : Multicenter analysis of data recorded between 2009 and 2012 in four German states]

BACKGROUND

Bearing in mind the impending evaluation of newborn hearing screening in Germany, this study investigated whether multicenter analysis of the screening results from four German states is possible and to what extent the results meet national quality and outcome criteria.

MATERIALS AND METHODS

The screening data from 170 hospitals and a total of 533,150 newborns (21 % of all German newborns) from 2009 to 2012 were evaluated according to definite rules and analyzed in terms of averages, as well as over time.

RESULTS

During the investigated period and averaged over the hospitals, the quality criteria "percentage of screened newborns" (91.4 %) and "percentage requiring further follow-up" (5.0 %), the "day of screening" (day 4), as well as the target parameter "age at diagnosis" (4.8 months) were not met. Steady improvements were observed over time: in the last year of the evaluation, 95.3 % of children were examined; only 4.8 % required follow-up and the age at diagnosis decreased to 4.2 months. On average, 83 % of the babies were screened before day 4. The steady reduction in variance of most of the variables from the participating hospitals indicates continual improvement.

CONCLUSION

A multicenter analysis of screening data is possible and valid in the case of good quality data.

[Pedaudiological diagnostics in the first year of life . Clinical follow-up, risk factors, and middle ear function]

The universal neonatal hearing screening (UNHS) program demands detection of hearing loss within the first 3 months of life. Practicability and different screening methods should be evaluated. Thus, 617 patients (329 m., 288 w.) were analyzed; 246 children were referred in the UNHS, 389 with risk factors. In 459 children (74%), automated auditory brainstem response (ABR) screening in our department excluded hearing loss, thereof 129 (21%) underwent diagnostic auditory brainstem-evoked audiometry responses: 20 (16%) showed normal and 109 (84%) elevated ABR thresholds. A total of 91 children (83%) received hearing aids and 11 children (10%) treatment of middle ear effusion. Hearing loss was diagnosed in 18% of all children, 24% with UNHS referral and 34% with both referral and risk factors. Craniofacial anomalies, premature birth < 32 weeks of pregnancy, and syndromes were the most frequent risk factors. Reevaluation by ABR showed an improvement to normal hearing in 3 (of 14) children. The 226 Hz compared to 1,000 Hz-tympanometry showed different specificity (95.5 vs. 85.5%) and sensitivity (32.5 vs. 57.1%). Diagnosis within 3 months is possible, but very challenging in children with risk factors.

Validation of a new TEOAE-AABR device for newborn hearing screening

OBJECTIVE

Because newborn hearing screening (NHS) programs are currently implemented in an increasing number of countries, physiological NHS technologies have to be continuously optimized. This study validates a new TEOAE-AABR screening device.

DESIGN

TEOAE and AABR screenings were performed in 299 ears with both the new NHS device and a well-established and validated one. Furthermore, 49 ears, suspected of having a hearing loss, underwent the screenings and an additional diagnostic ABR.

STUDY SAMPLE

One hundred and fifty newborns and infants were included in the study (median age 1.0 months, range 0-54 months; among them 39 babies from neonatal intensive care units).

RESULTS

Screening with both devices resulted in a concordance of κ =.98 for TEAOE measurements and .96 for AABR measurements. The mean measurement durations were significantly shorter for the new device than for the established one for both TEOAE (15.4 vs. 17.2 s) and AABR (26.6 vs. 32.7 s).

CONCLUSIONS

The algorithm of the new screening device is as valid as that for the established one. The shorter test durations with the new device facilitate hearing screenings and allow for a higher number of valid measurements in restless children than with former comparable procedures.

Universal newborn hearing screening, a revolutionary diagnosis of deafness: real benefits and limitations

The finding that early detection of permanent congenital childhood hearing loss produces worthwhile benefit in terms of improved speech and language provides the rationale for the universal screening of newborns. The aim of the present study is to collect the current evidence with regard to the efficacy, the results and outcomes of universal hearing screening programs. An extensive search of the literature was performed in Medline and other available database sources. Study selection was based on the evaluation of the protocols used and the assessment of their efficacy in the early diagnosis of congenital hearing impairment. The initial referral rate and the rate of false positives were also evaluated. A total of 676,043 screened children have been identified in 20 studies. The average initial referral rate in these studies was 3.89%. The initial referral rate varied from 0.6 to 16.7%. The lost-to-follow-up rates varied from 3.7 to 65%. Although universal hearing screening is now widely adopted, there are still some serious drawbacks and limitations. False positives rates remain considerably high when newborns are screened with TEOAE's. The combination of TEOAE's and a-ABR provides a significantly reduced referral rate. Close cooperation between audiological centres and maternity units and a dedicated secretariat team are of paramount importance with regard to the reliability and efficacy of universal hearing screening.

Interdisciplinary approach to design, performance, and quality management in a multicenter newborn hearing screening project. Discussion of the results of newborn hearing screening in Hamburg (part II)

Previously presented results of the newborn hearing screening in Hamburg and the perspectives are subsequently discussed. Minimum standards referring a participation of 95% of the neonates and a fail rate of less than 4% hearing-impaired children at the primary screening are fulfilled in Hamburg. Systematic screening of newborn hearing by an interdisciplinary approach provides early identification and intervention for children with permanent unilateral and bilateral hearing loss. But a newborn hearing screening on a voluntary basis alone cannot be maintained in the long run. Further, an anonymous data collection is not sufficient in regard to an uninterrupted tracking of conspicuous and unscreened neonates. A lost-to-follow-up rate of 31.3% at primary screening in Hamburg is much too high and emphasizes the need for a public health approach to a population-based newborn hearing screening with an elaborate and name-based tracking system. The legislation and implementation of a nationwide newborn hearing screening program in Germany and the association of German newborn hearing screening centers are highlighting long efforts of hearing professionals. But the implementation of a newborn hearing screening only makes sense if there exists an efficient tracking system. Sad to say, we are still a long way from the implementation of such a tracking system.

Early detection of hearing loss

The universal newborn hearing screening (UNHS) is currently spreading in Germany, as well, even though there can be no talk of a comprehensive establishment. The introduction of UNHS in several federal states such as Hamburg, Hessen, and Schleswig-Holstein can be ascribed to the personal commitment of individual pediatric audiologists. Apart from the procurement of the screening equipment and the training of the staff responsible for the examination of the newborns, the tracking, i.e. the follow-up on children with conspicuous test results, is of utmost importance. This involves significant administration effort and work and is subject to data protection laws that can differ substantially between the various federal states. Among audiologists, there is consensus that within the first three months of a child's life, a hearing loss must be diagnosed and that between the age of 3 and 6 months, the supply of a hearing aid must have been initiated. For this purpose, screening steps 1 (usually a TEOAE measurement) and 2 (AABR testing) need to be conducted in the maternity hospital. The follow-up of step 1 then comprises the repetition of the TEOAE- and AABR measurement for conspicuous children by a specialized physician. The follow-up of step 2 comprises the confirmatory diagnostics in a pediatric audiological center. This always implies BERA diagnostics during spontaneous sleep or under sedation. The subsequent early supply of a hearing aid should generally be conducted by a (pediatric) acoustician specialized on children.

[Surgical technique in cochlear implantation]

The cochlear implant (CI) has become a standard option for treating prelingually deaf children. But postlingual late deafness in adults is becoming increasingly common. In addition, hybrid implantation with a CI and a hearing aid in the same ear has come into focus, which demands a soft insertion technique that spares the apical parts of the cochlea. Also, the chorda tympani should be saved, especially in bilateral implantations, which are gaining importance because improved speech discrimination in noisy conditions is seen as proven today. Control of the electrode position intraoperatively with intraoperative computed tomography can further increase the safety and reliability of the position. The position and length of the skin incision is a more aesthetic issue. Future developments will include fully implantable CIs and navigation-assisted, minimally invasive drilling of a hole from the surface of the skull into the cochlea. Bioactive, neurotrophic-drug-releasing electrode designs for improved and sustainable connectivity to the neurons may become applicable.

[Quality assurance of a universal newborn hearing screening. Recommendations of the German Society of Phoniatrics and Pediatric Audiology]

Statutory implementation of a universal newborn hearing screening requires a continuous quality assurance monitoring. Therefore, at the Annual Meeting in 2007, the members of the German Society of Phoniatrics and Pediatric Audiology passed a recommendation on measures of quality assurance applied to newborn hearing screening. This recommendation describes the procedures, performance, location, time frame, and technical prerequisites of the screening and of potentially necessary follow-ups, the definition of hearing loss to be detected, the performing and responsible professional groups and their qualifications for the screening, the regulation of repeat and control screenings, the confirmation diagnostics and initiation of therapy, the information of parents, the documentation of screening results, the aims and organization of a tracking system, the tasks of regional screening centers and of a supraregional institution for the quality assurance of the hearing screening, the central collection of person and screening-related quality relevant data, and the accessibility of defined data sets as predisposition for cost analyses and quality reports.

[Universal newborn hearing screening. Methodical aspects]

BACKGROUND

In order to prepare for the introduction of a universal newborn hearing screening program on a larger scale, TEOAE and ABR were recorded on automated screening instruments from both ears of 501 newborns at the University Hospital Heidelberg over a period of 13 months. The parents of children in whom OAE and ABR could not be detected in both ears, were requested to allow a complete exploration of the auditory status of the children at the department of pediatric audiology.

SUBJECTS AND METHODS

Internally available data networks were used for the acquisition and evaluation of data and for the organization of tracking and follow-up. Of the children 35% exhibited risk factors for congenital hearing impairment.

RESULTS

The pass rate was 98.7% for the exclusion of binaural and 91.6% for monaural hearing disorders (TEOAE or ABR detectable). On the basis of the data it can be shown how pass rates can be optimized by selecting a suitable moment for the examination and by prescribing a minimum number of test repetitions (3 for TEOAE and 2 for AABR).

CONCLUSION

Quality control of screening programs should include these parameters and, in particular the number of repetitions of test measurements in all screening steps.

[Cost analysis of a universal newborn hearing screening for clinics using the State of Hesse as an example]

BACKGROUND

The implementation of a universal newborn hearing screening (UNHS) in Germany in 2009 requires a realistic cost calculation for health insurance companies and participating clinics

MATERIAL AND METHODS

Screening costs from 60 Hessian clinics were analyzed over 2.5 years whereby 94,203 children had been screened either with a 2-step (TEOAE, AABR) or a 1-step procedure (AABR).

RESULTS

The TEOAE-AABR screening at EUR 13.16 per child was more cost-efficient. For a population with a high rate of at-risk babies a sole AABR device with screening costs of EUR 16.87 presents a more efficient alternative. High quality of screening performance and qualification of screening staff markedly reduced total cost. Overhead costs for tracking, quality assurance, control of completeness, and securing structural screening requirements, considered as essential screening costs, were calculated at EUR 4.00 per child. The total costs in Hesse would therefore be EUR 17.16 per child for TEOAE-AABR screening and EUR 20.87 per child for an AABR screening.

CONCLUSION

In a mixed calculation which can be cautiously extrapolated from the Hessian data for Germany as a whole, costs would be EUR 18.40 per registered child.

Receptive (aural) vocabulary development in children with permanent bilateral sensorineural hearing impairment

Objective:

The receptive (aural) vocabulary development of children with binaural-aided residual hearing was investigated in a prospective longitudinal analysis (repeated measures).

Patient and methods:

Thirty-three children with sensorineural hearing loss, without major co-morbidities (mean age at the first testing point, 56.2 months, standard deviation 19.0 months) were recruited from the 1994 German Goettinger Hearing Language Register. Their receptive vocabulary was measured using standardised tests (with reference to normal hearing child performance) on three separate test points (mean follow up, 18.7 months, standard deviation 5.0 months).

Results:

On average, the study group scored below the normal range at the first and second tests and made a significant improvement at the last test. The degree of hearing loss was found to be significantly correlated to vocabulary performance at all time points, with increasing correlation coefficients. At the third test, significant predictive variables for successful receptive vocabulary outcome were found to be: degree of hearing loss (t = 5.43; p < 0.0001); age at diagnosis (t = 2.29; p = 0.03); and nonverbal intelligence (t = 2.82; p = 0.009).

Conclusion:

If permanent childhood hearing impairment is mild and/or is detected early, and if the child grows up in a monolingual environment, the development of receptive vocabulary within the normal range is possible.