Beyond newborn screening: early diagnosis and management of hearing loss in infants

Factors Affecting Neonatal Hearing Screening Follow-up in Developing Countries: One Insitution Prospective Pilot Study

Objective

To detect factors related with loss to follow-up (LTF) in neonatal hearing screening (NHS) program of one institution in a developing country.

Methods

A prospective study was planned based on the data collected in a pilot study conducted a year before in the same institution. In this pilot study, hearing screening was performed before hospital discharge for every infant (1217 newborns) in six months period. Total referral rate was 19.1% (223/1217). Loss to follow-up (LTF) was 38.1% (85/223). Telephonic interviews were done with 50 parents who had not come with their child to the second hearing test. For these telephonic interviews the questionnaire with four sections (socio-demographic information; information about pregnancy, birth, and present health condition of the child; caregiver knowledge of neonatal hearing screening, and reasons for default on follow-up) was created.

Results

The mothers participated in this study were 29.1 years (±5.2 SD) of age in average. Place of residence was mostly rural (64%; n=32) with 39.4 Km (±24.8 SD) away from from the rescreen referral center. Their knowledge on neonatal hearing screening, hearing impairment incidence or treatment opportunities was at a very low level. Caregivers’ perceptions that follow-up was unnecessary (50%; n=25), was most frequently given reason for follow-up default, followed by newborns bad health condition (12%; n=6) and forgetting about the follow-up visits (8%; n=6).

Conclusion

The main reason for default in follow-up in our study was caregiver’s poor knowledge about this topic.

Stability of ABR Wave V Threshold in Early Hearing Diagnostics in Children from Selected Groups at Risk of Congenital Hearing Loss

<b>Introduction:</b> Upon hearing that the "little" patient has trouble with hearing, we are mostly interested in the level of his hearing threshold. When the child is in the first year of life, results can only be achieved by means of ABR test. Subsequent control tests, especially in children from the hearing loss risk groups selected in this study, show that the obtained outcomes are subject to fluctuations. Their fluctuating nature is manifested by the instability of wave V threshold in subsequent diagnostic periods. Such variability often delays the implementation of the appropriate proceeding. Knowledge of the dissimilarity of behavior of the wave V threshold occurring in individual groups at risk of hearing loss allows for the correct interpretation of the obtained results, and thus, effective therapeutic measures. <br><b>Aim:</b> The aim of the paper is to analyze the stability of wave V threshold during the first year of life in children from selected risk groups for congenital hearing disorders. <br><b>Material and methods:</b> From the patient population of 2,114 individuals examined in 2015-2016 at a reference center participating in the Universal Neonatal Hearing Screening Program in 2015-2016, the results of 250 children were subjected to retrospective analysis. Furthermore, 4 groups of little patients were formed (children with Down syndrome; children with other diseases or damage to the nervous system; children with cleft palate or cleft lip and cleft palate; children with congenital cytomegaly) in whom diagnostic practice revealed variable results of the wave V threshold. We analyzed the results of tests obtained during the first year of the child's life divided into 4 diagnostic periods. <br><b>Results:</b> The highest percentage of instability in the established threshold of wave V between individual diagnostic periods occurred in the group of children with cleft palate or cleft lip and cleft palate. In the group of children with Down syndrome, it was observed that the instability of the ABR test results decreased over time. In the group of children with other diseases or damage of the nervous system, the highest percentage of the lack of stable ABR wave V thresholds was observed between the 1st and 2nd as well the 1st and 4th diagnostic periods. On the other hand, in the group of children with congenital CMV, there was a relatively low percentage of instability of results. <br><b>Conclusions:</b> (1) Although the ABR test is a diagnostic standard, in particular groups of patients the study is burdened with high variability of measurement results in subsequent diagnostic periods. Such a group of patients are children with cleft palate or cleft lip and cleft palate; therefore, it must receive particular attention in treatment planning; (2) in selected groups at risk of hearing loss, due to the high percentage of children with hearing impairment (70%), the validity of performing newborn hearing screening tests was confirmed.

Limitations and drawbacks of the hospital-based universal neonatal hearing screening program: First report from the Arabian Peninsula and insights

OBJECTIVES

To assess the efficacy of the current universal neonatal hearing screening program in a tertiary medical institution in Oman, identify its limitations and drawbacks, and explore their causative factors.

METHODS

A retrospective review was carried out to analyse the hearing screening of 12,743 live babies born between January 2016 and December 2018. Screen coverage, drop outs, follow up rate, and age at completion of screening, diagnosis, and intervention were analysed. The results were compared with the Joint Committee on Infant Hearing (JCIH) performance quality indices. Prospective questionnaire-based telephonic interviews were then conducted with the parents or caregivers of neonates with hearing loss. Finally, the causes of loss to follow up or delays in hearing screenings, diagnosis, and/or early intervention were studied.

RESULTS

The true prevalence of hearing loss was 4.0 in 1000. The coverage of first-stage screening was 90% whereas the compliance with the second stage was 88.04%. 22.8% of the patients eventually obtained final diagnostic confirmation. The overall compliance with amplification was 30.2%. The completion ages of primary screening and final confirmation were 7.98 and 17.3 weeks respectively. The importance of hearing screening is well received by parents, but problems related to communication, delays in the appointment system, and inefficient follow up tracking were identified as the main limitations and drawbacks of the program.

CONCLUSION

The coverage of the neonatal hearing screening program had not yet reached the required goal of 95%. The performance indicators also fell below the international benchmark. There is a need to address the identified causative factors. Effective communication and well-maintained tracking systems need to be implemented.

Factors Related to Not Following Up with Recommended Testing in the Diagnosis of Newborn Hearing Loss

Children's hearing is a public health concern, and universal newborn hearing screenings are the first step in detecting and treating congenital hearing loss. Despite the high rate of participation in such programs, loss to follow-up (LTF) with additional recommended diagnosis and treatment has been a persistent problem. The current research seeks to expand the knowledge base at the point of diagnosis, where there is a large drop-off in parents following through with recommended care. This research was organized around the following question: What biopsychosocial factors are associated with LTF between screenings and diagnostic evaluations? A prospective quantitative longitudinal study tracked 203 families whose newborns were referred for additional testing at discharge from the hospital after birth. Binary logistic regression was used to determine what constellation of factors best predicted LTF. Psychosocial factors related to being lost to follow-up at diagnosis included race and ethnicity and access to health care professionals, with African American babies being most at risk for LTF; however, the impact of race and ethnicity declined when parents believed they had more health care professionals with whom to consult.

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.

On the threshold of effective well infant nursery hearing screening in Western Sicily

OBJECTIVE

To determine the feasibility and effectiveness of well-infant nursery hearing screening programme for the early identification of hearing impairment, based on transient evoked otoacoustic emission (TEOAE) with a high "screen sensitivity" reducing the number of more expensive secondary level exams.

METHODS

The newborns were screened by non-specialist health workers in well babies nursery at the twentieth day of life for 6 years consecutive. Based on PASS/FAIL criteria and presence/absence of audiological risk factors the newborns were divided into four groups each one with its personal step programme: G1 - PASS without risk factor, free to go home; G2 - PASS with risk factor, retest at the age of 7 months; G3 - FAIL without risk factor, re-screening after 2 weeks for a maximum of four times before audiology assessment; G4 - FAIL with risk factor, retest after 2 weeks.

RESULTS

The coverage rate increased progressively from 89.8% to 92%. The referral rate was 1.51% after second stage with a specificity value of 98.78%. The four-stage screening performed for G3 reduced the numbers of global audiology assessment to 0.91% with a final global specificity of 99.4 ± 0.4%.

CONCLUSION

Less than 1% of infants underwent audiological assessment; the false positives resulted 0.62% with hearing loss global incidence of 2.95/1000 and a mean age of confirmation of 3.5 months of age. It is reasonable to think that this screening programme could be implement to overall 42 Western Sicily birth centres within few years.

Infant hearing screening: effects of timeline

OBJECTIVES

Universal infant hearing screening using otoacoustic emission and auditory brain-stem response audiometry is widely administered to attain the goals of early identification of, and intervention for hearing impairment. Concerns regarding screening specificity have, however, been raised. False positives may result from vernix occlusion in the ear canal or transient middle ear effusion, and can result in substantial costs to health care systems. The current study investigates the effects of age and time interval between tests on hearing assessment results.

SETTING & PARTICIPANTS

Three hundred and seventeen positive screens from a 2-stage distortion product otoacoustic emission (DPOAE) screening programme in Hong Kong, who subsequently received diagnostic auditory brainstem response (ABR) assessment and monitoring, were investigated.

MAIN OUTCOME MEASURES

Differences in diagnostic ABR results were compared among infants of different ages at tests, and with different time lapses after DPOAE screening. The proportion of those having persistent hearing impairment, conductive loss and impairment of moderate degree or above, were also compared.

RESULTS

A significantly higher rate of normal ABR thresholds (60%versus 24%) was noted in infants assessed after age 50 days, and in infants diagnostically assessed with a time lapse of over 20 days post-DPOAE screening (65%versus 42%).

CONCLUSIONS

Delaying diagnostic ABR assessment may reveal a higher percentage of normal thresholds, and hence probably higher specificity. Time delay may allow for spontaneous resolution of transient outer and middle ear conditions. However, the goals of early identification and intervention, as well as possible parental anxiety with delayed assessment, should also be considered when reviewing infant hearing screening schedules.

Newborn hearing screening project using transient evoked otoacoustic emissions: Western Sicily experience

OBJECTIVE

To study the incidence of congenital sensorineural hearing loss in all newborns introducing a screen test with a protocol no expensive, with a good "screen sensitivity" that could let an earlier identification of hearing impairment beginning early intervention by 2 months of age and increasing the probability of having language development within the normal range of development.

METHODS

The study was conducted in Sciacca hospital from the beginning of 2003 to our days and was carried out with transient evoked otoacoustic emission using the criteria for PASS or RETEST and considering eventual prenatal and perinatal risk factors. All the newborns were divided into four groups each one with its personal secondary step program.

RESULTS

In the years 2003-2004 the number of the newborns in Sciacca hospital was: 538 for 2003, 653 for 2004 with a total of 1191; all these infants were divided in three groups: resident in Sciacca, resident in the Sciacca borderlands and resident out of the district of Sciacca. The coverage (percentage of the target population who undergo the screen) was of 90% in the 2003 (483 newborns) and of 90% in the 2004 (585 newborns) with two cases of congenital sensorineural hearing loss identified. The incidence of sensorineural hearing loss, in the District of Sciacca, was estimated to be 2.07/1000 in 2003 and 1.70/1000 in 2004.

CONCLUSIONS

The higher incidence of sensorineural hearing loss in our study is due to a high prevalence of consanguineous marriage in Sicily that was shown to be linked with hearing impairment. The "sensitivity value" was 95% at the first step but became 99% after the second step with a few number of false positive (0.74%). All the infants with a diagnosis of sensorineural hearing loss began a rehabilitation program before the age of 5 months and they have a good speech development and speech intelligibility.