The New York State universal newborn hearing screening demonstration project: ages of hearing loss identification, hearing aid fitting, and enrollment in early intervention

Universal newborn screening: a dream realized or a nightmare in the making?

There is a very strong movement to develop universal newborn hearing screening. This effort is the end product of a long international research effort to determine the most effective means to screen newborns. Now that OAE and ABR together offer a superior mechanism to achieve universal screening, problems related to middle ear effusion, non-high-risk children and adequate resources for all aspects of identification, diagnosis and treatment have come to the fore. Further, what to do in the developing world is also a major problem as audiology embarks on this exciting new frontier. This paper discusses some of the issues, raises some concerns and offers a few small solutions.

Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study

OBJECTIVE

To estimate the prevalence of confirmed permanent childhood hearing impairment and its profile across age and degree of impairment in the United Kingdom.

DESIGN

Retrospective total ascertainment through sources in the health and education sectors by postal questionnaire.

SETTING

Hospital based otology and audiology departments, community health clinics, education services for hearing impaired children.

PARTICIPANTS

Children born from 1980 to 1995, resident in United Kingdom in 1998, with severe permanent childhood hearing impairment (hearing level in the better ear >40 dB averaged over 0.5, 1, 2, and 4 kHz).

MAIN OUTCOME MEASURES

Numbers of cases with date of birth and severity of impairment converted to prevalences for each annual birth cohort (cases/1000 live births) and adjusted for under ascertainment.

RESULTS

26 000 notifications ascertained 17 160 individual children. Prevalence rose from 0.91 (95% confidence interval 0.85 to 0.98) for 3 year olds to 1.65 (1.62 to 1.68) for children aged 9-16 years. Adjustment for under ascertainment increased estimates to 1.07 (1.03 to 1.12) and 2.05 (2.02 to 2.08). Comparison with previous studies showed that prevalence increases with age, rather than declining with year of birth.

CONCLUSIONS

Prevalence of confirmed permanent childhood hearing impairment increases until the age of 9 years to a level higher than previously estimated. Relative to current yields of universal neonatal hearing screening in the United Kingdom, which are close to 1/1000 live births, 50-90% more children are diagnosed with permanent childhood hearing impairment by the age of 9 years. Paediatric audiology services must have the capacity to achieve early identification and confirmation of these additional cases.

[Systematic screening of deafness at a maternity ward using evoked otoacoustic emissions: practical aspects and parental attitudes]

OBJECTIVE

Evaluation of the feasibility and parental attitudes towards a hearing screening programme using evoked otoacoustic emissions, implemented in a maternity ward in France.

METHODS

A hearing screening test using transiently evoked otoacoustic emissions (TEOAE) was proposed to each baby, and an anonymous questionnaire was given to parents to assess their attitudes towards the screening procedure.

RESULTS

Although the refusal of the test reached 16% (mainly during the first two weeks of the program), more than 92% of parents judged the test as being useful, and 65% wished it to be systematically done. However, nearly 35% of parents admitted to have a low level anxiety about being unnecessarily worried by the test results. One hundred and twenty-four babies were screened. Fifty three per cent of the tests have been performed in less than ten minutes, with an average of 12.2 minutes. This duration does not include delays due to programme and babies management. False positive rate (uni or bilateral fail) was 10.5% at the first stage. Repeating the test before discharge decreased the false positive rate to 6.5%.

CONCLUSION

Although limited in time, this study shows that a systematic hearing screening programme using TEOAE is possible and should be done in France. False positive rate was below 7%, and the test was considered as useful by more than 90% of parents, although knowledge about deafness in childhood and its consequences were clearly insufficient.

Parents' reactions and recommendations after diagnosis and hearing aid fitting

This study was designed to explore parent reactions to the early stages of audiologic assessment and intervention. A total of 213 parents whose children were under the age of 6 years returned a mail survey. Respondents from 45 states participated. Parents were asked to (1) report the approximate age of diagnosis and hearing aid fitting; (2) comment on reasons for any delays encountered from diagnosis to fitting; and (3) respond to questions concerning their reactions to the initial fitting of amplification. The median age of identification was earlier than some previous investigations; however, substantial delays occurred between diagnosis and hearing aid fitting. Reasons for delay included the need for further audiologic evaluation, problems obtaining return appointments, illness of the child, and difficulties obtaining adequate earmolds. Parent reactions to hearing aids, once fitted, included concerns about appearance and questions about maintenance and use, but attitudes regarding hearing aids and their perceived benefits improved over time.

Universal neonatal hearing screening: past, present, and future

After a brief review of the history of newborn hearing screening including the Downs behavioral testing procedure, the Crib-o-gram and similar devices, and the use of auropalpebral reflex and otoacoustic emissions, there is a discussion of key issues that need to be resolved before universal hearing screening is introduced. Included are questions regarding the target population(s) of screening programs, well baby versus NICU screening, dealing with false-positives and the effects on parent-child relationships, and finally, the availability of resources for screening and follow-up. The results of a recent study in the United Kingdom that assessed the current state of audiology services and found there is a difference between existing standards and what is actually being done in practice, are presented and considered in terms of current trends in the United States to move ahead with universal screening without a solid database of information regarding the preparedness of clinical centers to deal with the need for services that will result from the initiation of universal programs. Caution is urged.

The New York State universal newborn hearing screening demonstration project: introduction and overview

OBJECTIVE

To determine the feasibility of universal newborn hearing screening, including intervention of identified infants, in the state of New York.

DESIGN

The New York State Department of Health issued a request for proposals that invited regional perinatal centers to apply for funding to implement universal newborn hearing screening. Hospitals were free to choose their own protocols but were to use physiologically based measures to screen infants for possible hearing loss. Criteria for passing the screening measures were common across sites. Infants failing the screening were to have diagnostic testing. Identified infants were to be followed by the state's Early Intervention Program and its associated Infant-Child Health Assessment Program.

RESULTS

Seven regional perinatal centers (eight hospitals) representing the various regions of the state were funded for 3 yr to implement universal newborn hearing screening and follow-up of identified infants. Detailed data analysis was performed for inpatient, outpatient, and intervention outcome measures and for the various protocols. Most of the outcome measures were analyzed in terms of year of program operation, nursery type, and geographic region of the state.

CONCLUSIONS

Universal newborn hearing screening was feasible in regional perinatal centers across the state of New York. The average ages of identification of hearing loss, hearing aid fitting, and enrollment in early intervention were less than those reported in published studies where universal newborn hearing screening was not in place.

New York State universal newborn hearing screening demonstration project: effects of screening protocol on inpatient outcome measures

OBJECTIVE

To examine differences among various test protocols on the fail rate at hospital discharge for infants in the well-baby nursery (WBN) and neonatal intensive care unit (NICU) who received hearing screening through a universal newborn hearing screening demonstration project.

DESIGN

The outcomes of several screening protocols were examined. Two technologies were used: transient evoked otoacoustic emissions (TEOAEs) alone or in combination with the auditory brain stem response (ABR). The performance of test protocols in both nurseries within eight hospitals was examined over a 2- to 3-yr period. In the WBN, six hospitals used a screening protocol of TEOAE technology first followed by an ABR (automated or conventional) technology screening for newborns who referred on TEOAE screening. Two hospitals used TEOAE only in the WBN. Seven hospitals used screening protocols in the NICU that used a combination of TEOAE and ABR technologies (TEOAE technology administered first or second, before or after TEOAE, or TEOAE and ABR tests on all infants). Only one hospital used TEOAE technology exclusively for hearing screening.

RESULTS

Significant differences among screening protocols were found across hospitals in the first, second, and third years of the program. The combination of TEOAE technology and ABR technology (a two-technology screening protocol) resulted in a significantly lower fail rate at hospital discharge than the use of a single-technology (TEOAE). Fail rates at discharge were twice as high using the one-technology protocol versus two-technology protocol, even when the best outcomes from program year 3 were considered exclusively. Results of two-technology versus one-technology protocols were similar in the NICU. Use of a second technology for screening TEOAE fails significantly reduced every hospital that used the protocol's fail rate at discharge.

CONCLUSIONS

A two-technology screening protocol resulted in significantly lower fail rates at hospital discharge in both the WBN and NICU nurseries than use of a single-technology (TEOAE) hearing screening protocol.