Late Onset Hearing Loss in Very Low Birth Weight Infants

Objective

To determine the incidence of late onset hearing loss and associated risk factors in very low birth weight (VLBW) infants.

Study Design

Retrospective study (2003-2015) of post-discharge hearing outcomes and risk factors in the VLBW infant population, before and after the institution of a standardized follow-up program.

Results

Late onset hearing loss increased from 2.9 per 100 VLBW infants to 7.8 per 100 after instituting a monitoring protocol. The follow-up compliance rate nearly doubled. Both infants with late-onset sensorineural hearing loss and those with a conductive component were identified. The rate of conductive loss detection increased seven-fold.

Conclusion

The institution of a standardized hearing follow-up program significantly increased the detection of late onset hearing loss in VLBW infants. A significant proportion of those with late onset hearing loss had a conductive component. Without identification and treatment, even conductive losses may negatively impact speech and language development.

Current Issues With Pediatric Cochlear Implantation

Cochlear implants (CIs) have demonstrated a clear functional benefit in children with severe-to-profound sensorineural hearing loss (SNHL) and thus have gained wide acceptance for treating deafness in the pediatric population. When evaluating young children for cochlear implantation, there are unique considerations beyond the standard issues addressed during surgery in adults. Because of advances in genetic testing, imaging resolution, CI technology, post-implant rehabilitation, and other factors, issues related to CI surgery in children continue to evolve. Such factors have led to changes in candidacy guidelines, vaccine requirements, and lowering of age requirement for surgery. In addition, differences in the anatomy and physiology of infants require special attention to ensure safety when operating on young children. This review summarizes these issues and provides guidance for surgeons treating children with SNHL.

The challenge of a mature final diagnosis of hearing loss severity and early cochlear implantation

PURPOSE

Despite the recent trend of cochlear implantation (CI) at the age of six or even four months is prevalent in many centers around the world, clinicians should be cautious because perinatal risk factors of auditory neuropathy and/or delayed maturation carry the possibility of reversible hearing loss, yielding better auditory performance at the age of one year. The purpose of this study is to raise awareness that early CI may not be universal for all patients. In addition, we specify the factors to be considered in the pre-operative evaluation of CI in infants younger than one year.

METHODS AND RESULTS

This study describes four cases provisionally diagnosed with severe to profound sensorineural hearing loss that were presented to the CI clinic to determine candidacy for implantation. Two cases had histories of prematurity, one had Down syndrome, and one had a family history of hearing loss. None of the study cases were candidates for CI, as they had varying degrees of hearing improvement.

CONCLUSION

Although early CI may yield better auditory performance, the final diagnosis should be made only after repeated subjective and objective measurements as well as family feedback on the child's auditory performance, especially in preterm children. Early auditory brainstem response (ABR) prior to the age of one year in children with cognitive, neurologic, or developmental comorbidities should be interpreted with caution, as ABR "alone" could not accurately represent the child's true hearing ability in this patient population.

Vestibular Follow-up Program for Congenital Cytomegalovirus Based on 6 Years of Longitudinal Data Collection

OBJECTIVES

Congenital cytomegalovirus (cCMV), the leading nongenetic cause of pediatric sensorineural hearing loss, can also affect vestibular function. Literature findings suggest clinical presentation of vestibular loss in cCMV to be as variable as the hearing loss. Still, probably due to the considerable additional burden it entails for both patients and diagnostic centers, longitudinal vestibular follow-up in cCMV is not well-established in clinical practice. Therefore, this study aims to propose an evidence-based vestibular follow-up program with proper balance between its feasibility and sensitivity.

DESIGN

In this longitudinal cohort study, 185 cCMV-patients (mean age 3.2 years, SD 1.6 years, range 0.5-6.7 years) were included. Vestibular follow-up data were obtained through lateral video head impulse test (vHIT) and cervical vestibular evoked myogenic potential (cVEMP) evaluations around the ages of 6 months, 1 year, and 2 years. Around 3 and 4.5 years of age, data from vertical vHIT and ocular vestibular evoked myogenic potentials (oVEMP) were also collected.

RESULTS

At birth, 55.1% (102/185) of patients were asymptomatic and 44.9% (83/185) were symptomatic. The mean duration of follow-up for all patients was 20.8 (SD 16.3) months (mean number of follow-up assessments: 3.2, SD 1.5). Vestibular loss occurred at some point during follow-up in 16.8% (31/185) of all patients. Six percent (10/164) of patients with normal vestibular function at first assessment developed delayed-onset vestibular loss; 80.0% (8/10) of these within the first 2 years of life. Vestibular deterioration was reported both in patients who had been treated with postnatal antiviral therapy and untreated patients. At final evaluation, both the semicircular and the otolith system were impaired in the majority of vestibular-impaired ears (29/36, 80.6%). Dysfunctions limited to the semicircular system or the otolith system were reported in 4 (4/36, 11.1%) and 3 (3/36, 8.3%) ears, respectively. The occurrence of vestibular loss was highest in patients with first trimester seroconversion (16/59, 27.1%) or with an unknown timing of seroconversion (13/71, 18.3%), patients with sensorineural hearing loss (16/31, 51.6%), and patients with periventricular cysts on magnetic resonance imaging (MRI) (7/11, 63.6%).

CONCLUSIONS

Longitudinal vestibular follow-up, most intensively during the first 2 years of life, is recommended in cCMV-patients with vestibular risk factors (first trimester or unknown timing of seroconversion; sensorineural hearing loss; periventricular cysts on MRI). If those risk factors can be ruled out, a single evaluation early in life (around 6 months of age) might be sufficient. Both semicircular and otolith system evaluation should be part of the follow-up program, as partial losses were reported.

Downward trends in the global burden of congenital complete hearing loss in children younger than five years from 1990 to 2030

Background

The global epidemiological data on congenital hearing loss in children is sparse. We aimed to analyse the trends in the burden of complete hearing loss caused by congenital birth defects in children younger than five years from 1990 to 2030.

Methods

Using data from the Global Burden of Disease (GBD) Study 2019, we reported the counts and rates of prevalence and years lived with disability (YLD) by age, sex, and sociodemographic index (SDI). We also forecasted the prevalence rates until 2030 through the autoregressive integrated moving average (ARIMA) and Bayesian age-period-cohort (BAPC) models.

Results

We observed a global prevalence rate of 15.4 (95% uncertainty interval (UI) = 5.8 to 33.8) and a YLD rate of 3.3 (95% UI = 1.1 to 7.1) per 100 000 population in 2019, with both showing downward trends from 1990 to 2019. Regionally, Oceania had the highest prevalence (47.2; 95% UI = 18.8 to 96.6) and YLD (10; 95% UI = 3.2 to 22.8) rates, while Central Europe had the lowest rates. Nationally, the prevalence (85.0; 95% UI = 36.8 to 166.8) and YLD (17.9; 95% UI = 6.6 to 36.9) rates were highest in Myanmar and lowest in Peru. Only the United States of America (2.6%; 95% UI = -4.6 to 14.4) and Norway (0.6%; 95% UI = -6.7 to 16.2) showed upward trends. Compared to girls, the prevalence and YLD rates were higher for boys at global, regional, and five SDI quintile levels, except for Eastern Sub-Saharan Africa. At the global level, downward trends were predicted in prevalence rates from 2019 to 2030 between boys and girls.

Conclusions

Although the global burden of childhood congenital complete hearing loss showed inequalities across locations, sexes, and age groups, we found decreases in the global prevalence rates between 1990 and 2019 and predicted decreases from 2019 to 2030. Better prevention of infectious aetiologies, improving genetic diagnoses, and hearing restoration could alleviate this burden.

Maternal and child predictors associated with loss to follow-up in the newborn hearing screening program: a cohort study in maternity hospitals in northeastern Brazil

PURPOSE

Analyze maternal and child predictors associated with loss to follow-up in the newborn hearing screening program at maternity hospitals in northeastern Brazil.

METHODS

Retrospective cohort study, including secondary data from infants (n=604) referred to the newborn hearing screening program in two maternity hospitals for monitoring and/or diagnosis. The predictors evaluated included socioeconomic factors, such as maternal age, marital status, income, schooling, place of residence, number of children and number of prenatal visits. In addition, maternal and child health factors, such as smoking and drug intake during pregnancy, consanguinity, congenital infections, craniofacial malformations, use of ototoxic drugs, syndromes and a history of hearing loss in the family. Statistical analysis was performed based on binary logistic regression models, using the stepwise method.

RESULTS

The logistic regression model containing the number of prenatal visits and the history of hearing loss in the family was significant [χ2(2) =34.271; p<0.001]. The number of prenatal visits (OR = 2.343; 95% CI = 1.626 - 3.376) and family history of hearing loss (OR = 2.167; 95% CI = 1.507 - 3.115) were significant predictors. The other predictors were not significant.

CONCLUSION

The results reveal that newborns whose mothers had ≤ 5 prenatal visits and those with a family history of hearing loss increased their likelihood of loss to follow-up by 2.3 and 2.1 times, respectively. It is important to provide subsidies for public health improvements in order to help advise, guide and educate mothers, especially during prenatal care.

Hearing Outcomes in the Audiology Department of a Children Hospital

The incidence of sensorineural hearing loss is between 1 and 3 per 1000 in healthy neonates and 2-4 per 100 in high-risk infants. In this study, we assessed the incidence of hearing impairment in normal term (≥ 37 wga) infants (control group), in children with suspicion and/or risk factors of hearing loss, included premature infants (< 37 weeks gestational age (wga) and/or low birth weight < 2,5 Kgr), in children diagnosed with a specific syndrome and in children with speech disorder, candidate for speech therapy. Hearing impairment is a severe consequence of prematurity and its prevalence is inversely related to the maturity of the baby based on gestation age and /or birth weight. Both above parameters are of particular importance and it has not been found that one factor prevails over the other. Premature infants have many concomitant risk factors for hearing impairment. The most important other risk factors were ototoxic medications, very low birth weight and "treatment in the intensive care unit '' (low Apgar score and mechanical ventilation). Frequent risk factors such as congenital infections and family history of hearing loss, although frequently recorded, does not seem to be very significant. Children with speech disorder do not seem to suffer from hearing impairment more frequently than children in general population.

The validity of LENA technology for assessing the linguistic environment and interactions of infants learning Hebrew and Arabic

The present study assessed LENA's suitability as a tool for monitoring future language interventions by evaluating its reliability, construct validity, and criterion validity in infants learning Hebrew and Arabic, across low and high levels of maternal education. Participants were 32 infants aged 3 to 11 months (16 in each language) and their mothers, whose socioeconomic status (SES) was determined based on their years of education (H-high or L-low ME-maternal education). The results showed (1) good reliability for the LENA's automatic count on adult word count (AWC), conversational turns (CTC), and infant vocalizations (CVC), based on the positive associations and fair to excellent agreement between the manual and automatic counts; (2) good construct validity based on significantly higher counts for HME vs. LME and positive associations between LENA's automatic vocal assessment (AVA) and developmental questionnaire (DA) and age; and (3) good concurrent criterion validity based on the positive associations between the LENA counts for CTC, CVC, AVA, and DA and the scores on the preverbal parent questionnaire (PRISE). The present study supports the use of LENA in early intervention programs for infants whose families speak Hebrew or Arabic. The LENA could be used to monitor the efficacy of these programs as well as to provide feedback to parents on the amount of language experience their infants are getting and their progress in vocal production. The results also indicate a potential utility of LENA in assessing linguistic environments and interactions in Hebrew- and Arabic-speaking infants with developmental disorders, such as hearing impairment and cerebral palsy.

Status of the Newborn Hearing Screening in the 4-Months Age National Infant Health Checkup in Korea: A Nationwide Population-Based Study

BACKGROUND

The aims of this study are to review data on 4-months age National Health Screening Program for Infants and Children (NHSPIC) using a National Health Insurance Service (NHIS) database, and to analyze the newborn hearing screening (NHS) results and related characteristics of the 4-months NHSPIC for 7 years in South Korea.

METHODS

We analyzed a NHIS database of infants who had participated in the 4-month age NHSPIC from 2010 to 2016. According to the results of hearing questionnaires and physical examination, we analyzed the outcomes of NHS and related infantile and socioeconomic factors.

RESULTS

Among 3,128,924 of total eligible infants in Korea between the year 2010 and 2016, 69.2% (2,164,621 infants) conducted 4-months age NHSPIC, and 94.4% (2,042,577 infants) of which performed hearing questionnaires regarding NHS. Among the total hearing examinees, premature infants accounted for 3.6%, infants who were hospitalized in the neonatal intensive care unit (NICU) for more than 5 days accounted for 5.6%, and infants with head and neck abnormalities were 0.6%. The NHS performing rate was 79.1% for total hearing examinees in 2010, but gradually increased to 88.9% in 2016. The NHS performing rate in 2016 was 93.4% for premature infants, 91.7% for NICU hospitalized babies. The mean referral rate was 0.6% for total hearing examinees, 1.4% for premature infants, and 2.3% for NICU hospitalized babies. When we analyzed the NHS performing rate and the referral rate according to the household income level, the NHS performing rate of infants in Medical Aid programs was the lowest as 65.6%, and the NHS performing rates in other five levels of NHIS was higher ranging between 85.1% to 86.0%. The referral rate of infants in the Medical Aid program (3.8%) was significantly higher than those of infants in other classes (1.10-1.25%).

CONCLUSION

The estimated overall NHS performing rate in Korea gradually increased and was 88.9% in 2016. The overall referral rate was low as 0.6%, and it was significantly different depending on the infant's health condition and household income levels. We assume that our finding would help to establish policies managing hearing impaired children, and to develop the customized hearing care service programs considering the household economic levels.

Deaf Children Need Rich Language Input from the Start: Support in Advising Parents

Bilingual bimodalism is a great benefit to deaf children at home and in schooling. Deaf signing children perform better overall than non-signing deaf children, regardless of whether they use a cochlear implant. Raising a deaf child in a speech-only environment can carry cognitive and psycho-social risks that may have lifelong adverse effects. For children born deaf, or who become deaf in early childhood, we recommend comprehensible multimodal language exposure and engagement in joint activity with parents and friends to assure age-appropriate first-language acquisition. Accessible visual language input should begin as close to birth as possible. Hearing parents will need timely and extensive support; thus, we propose that, upon the birth of a deaf child and through the preschool years, among other things, the family needs an adult deaf presence in the home for several hours every day to be a linguistic model, to guide the family in taking sign language lessons, to show the family how to make spoken language accessible to their deaf child, and to be an encouraging liaison to deaf communities. While such a support program will be complicated and challenging to implement, it is far less costly than the harm of linguistic deprivation.

Cochlear Implants: Evaluation of Effects of Various Parameters on Outcomes in Pediatric Patients at a Tertiary Care Centre for Unilateral Ear Implantation

To determine whether variables such as Age, Gender, Demographic background of the patient and Pre-operative usage of hearing aids affect the outcomes of pediatric cochlear implant surgery when modified; in terms of speech and hearing gain. A hospital based retrospective-prospective type of cohort study was conducted over a period of 5 years at a Tertiary care Teaching hospital and referral centre covering a population of about 68.9 million. Candidates selected were 1-5 years of age with bilateral congenital severe-profound sensori-neural hearing loss. 50 patients were selected and were operated using VERIA technique of Cochlear Implant Surgery. Intraoperative testing of electrode functioning was done in all patients using NRT technique. The switching on of implant was done after 1 month, following which patients underwent 100 sessions of auditory verbal therapy and training. Outcomes were evaluated in terms of hearing and speech gain by using Revised CAP scores, ITMAIS scores and PEACH scores in the loco-regional language. Those implanted at a younger age and with at least 3 months of hearing aid usage pre-operatively had better outcomes measures. There was no effect on outcomes when the gender and demographic origin of the patient were compared. Candidates implanted before 3 years age give better results and they should be encouraged to use hearing aid regularly and continuously before the surgery and should be advised trial and fitting as soon as CI planning begins. Also, gender and demographic background should not be considered when planning CI as these have no significant effect on outcomes.

Universal Newborn Hearing Screening: An Indian Experience of Conceptualizing and Testing a Comprehensive Model

There have been isolated attempts to implement newborn hearing screening at various setups across India. However, none of these attempts has followed a holistic model comprising of multiple components. Therefore, a need was felt to design and implement a comprehensive universal newborn hearing-screening model to, improve follow-up, and provide practically implementable solutions for developing economies. The model was conceptualized after a detailed preliminary planning level. Separate protocols for newborns from well-baby nursery and neonatal intensive care unit were implemented. Measures were implemented to improve follow-up. Knowledge, attitude, and practices survey followed by a sensitization program was carried out to highlight the importance of newborn hearing screening among the healthcare providers. A knowledge and attitude survey was also carried out among mothers. The estimated prevalence rate was 8.78 per 1000. Measures enabled an improved follow-up rate that lead to a reduced age of identification to 6 months. The surveys among mothers and healthcare providers helped to identify the lacunae in knowledge levels, which need to be filled in order to improve their attitudes. Thus, this was a successful model for universal newborn hearing screening comprising of two-stage screening, separate protocols, steps to improve follow-up, improving awareness among parents, sensitization programs, and surveys among mothers as well as healthcare providers.

Main outcomes from the first two years of France's screening programme for neonatal permanent hearing loss through a descriptive study

AIM

This study aimed to evaluate the implementation of France's neonatal hearing loss screening programme two years after its launch, and to estimate permanent bilateral neonatal hearing loss (PBNHL) prevalence and distribution by severity.

METHODS

This descriptive study used aggregated regional data on all births in France in 2015-2016. Screening coverage, refusal rate, positive predictive value (PPV), proportion of children with suspected PBNHL, PBNHL prevalence and distribution by severity were calculated.

RESULTS

800,000 neonates were eligible for the screening programme per year. Between 2015 and 2016, screening coverage increased (83.3 vs 93.8%; p<0.001), and the refusal rate remained stable (0.1%). In 2016, when considering the additional tests performed several weeks after birth, the proportion of suspected PBNHL neonates decreased (1.4 vs 0.9%) while the PPV increased (4.7 vs 7.6%). In 2015, the estimated prevalence of PBNHL (moderate to profound) was 0.09% (95% CI 0.08-0.10). Among neonates with >=41 decibels deficit, 56.8%, 16.6%, and 26.6% had moderate, severe and profound hearing loss, respectively.

CONCLUSION

The national target of 90% screening coverage was exceeded. The additional test could be useful to avoid overcrowding in diagnostic structures. Diagnostic data quality must be improved to confirm PBNHL prevalence and distribution by severity.

Analysis of Health Disparities in the Screening and Diagnosis of Hearing Loss: Early Hearing Detection and Intervention Hearing Screening Follow-Up Survey

PURPOSE

The purpose of this study was to (a) provide introductory literature regarding cultural constructs, health disparities, and social determinants of health (SDoH); (b) summarize the literature regarding the Centers for Disease Control and Prevention (CDC) Early Hearing Detection and Intervention (EHDI) Hearing Screening Follow-Up Survey (HSFS) data; (c) explore the CDC EHDI HSFS data regarding the contribution of maternal demographics to loss-to-follow-up/loss-to-documentation (LTF/D) between hearing screening and audiologic diagnosis for 2016, 2017, and 2018; and (d) examine these health disparities within the context of potential ethnoracial biases.

METHOD

This is a comprehensive narrative literature review of cultural constructs, hearing health disparities, and SDoH as they relate to the CDC EHDI HSFS data. We explore the maternal demographic data reported on the CDC EHDI website and report disparities for maternal age, education, ethnicity, and race for 2016, 2017, and 2018. We focus on LTF/D for screening and diagnosis within the context of racial and cultural bias.

RESULTS

A literature review demonstrates the increase in quality of the CDC EHDI HSFS data over the past 2 decades. LTF/D rates for hearing screening and audiologic diagnostic testing have improved from higher than 60% to current rates of less than 30%. Comparisons of diagnostic completion rates reported on the CDC website for the EHDI HSFS 2016, 2017, and 2018 data show trends for maternal age, education, and race, but not for ethnicity. Trends were defined as changes more than 10% for variables averaged over a 3-year period (2016-2018).

CONCLUSIONS

Although there have been significant improvements in LTF/D over the past 2 decades, there continue to be opportunities for further improvement. Beyond neonatal screening, delays continue to be reported in the diagnosis of young children with hearing loss. Notwithstanding the extraordinarily diverse families within the United States, the imperative is to minimize such delays so that all children with hearing loss can, at the very least, have auditory accessibility to spoken language by 3 months of age. Conscious awareness is essential before developing a potentially effective plan of action that might remediate the problem.

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).

Knowledge, attitude and management of hearing screening in children among family physicians in the Kingdom of Saudi Arabia

BACKGROUND

Early detection and management of hearing loss are important to develop ordinary speaking language and academic skills during childhood. Lack of knowledge by either parents or health care providers could hinder the process of hearing loss diagnosis, such that the intervention will be less effective. There is little evidence about the knowledge and practice of family physicians regarding hearing screening in Saudi Arabia and worldwide.

OBJECTIVES

This study aimed to assess family physicians' knowledge, attitudes, and practices related to hearing loss in children. This in turn will help policy makers and educational institutions to establish and promote a program concerned with screening, diagnosis and intervention of paediatric hearing loss.

METHODS

A cross-sectional descriptive study enrolled 133 family physicians working at primary health centres in Saudi Arabia from March 2020 to September 2020. A self-reported questionnaire was used to assess the knowledge, attitudes, and practices of family physicians concerning hearing loss in children.

RESULTS

The majority of the participants were working under the umbrella of the Ministry of Health and around half of them did not screen any child for hearing loss. Despite that, 91.7% indicated the importance of neonatal hearing screening, 70.7% indicate infant candidacy for cochlear implant and only 33.1% know about the existence of the early hearing detection and intervention (EHDI) governmental program in kingdom of Saudi Arabia (KSA). Participants were able to identify factors associated with hearing loss such as a family history of hearing loss (85.6%), meningitis (75%) and craniofacial anomalies (51.5%). The most frequent specialists for patient referrals were ear nose and throat ENT (75.2%) and audiologists (67.7%).

CONCLUSION

This study shows that family physicians have good general background about the benefits of EHDI programs and the management of hearing loss in the paediatric population. However, it also indicated insufficient knowledge in other domains of hearing loss, including assessments and the presence of the EHDI governmental program in KSA. Further actions on the involvement of family physicians in the process of neonatal hearing screening, diagnosis and intervention for hearing impairment are needed.

Universal newborn hearing screening in the Italian Region of Sicily in 2018

OBJECTIVES

We have clarified the role of Universal Neonatal Hearing Screening (UNHS) for both early diagnosis and rapid treatment in order to improve the prognosis of the deaf child and reduce patient management costs. Although in Sicily UNHS has been progressively implemented, there is scarce data in the literature on this matter. Therefore, the main objective was to collect in the year 2018 the following data: number of newborns screened for hearing loss, number of infants "referred" to transiently evoked otoacoustic emissions (TEOAE), number of infants with pathologic auditory brainstem response (ABR) and number of infants affected by permanent hearing loss.

METHODS

UNHS monitoring was conducted through the collection of data through a questionnaire, which was analysed evaluating the effectiveness and adherence to the screening program prepared by the Department for Health Activities and the Epidemiological Observatory (DASOE).

RESULTS

In 2018, there were 40,243 newborns in Sicily. A total of 37,562 newborns were screened (93.3%). There were 1,328 "referred" infants with TEOAE (3.5%). On the 2nd level, "referred" newborns examined were 1,080 of 1,328 expected (missing 248 "refer" newborns, equal to 18.6%). The number of "referred" infants confirmed with TEOAE was 113 of 1,080, while "referred" infants confirmed with ABR were 71. On the 3rd level, 67 of 71 were infants examined: 28 infants were suffering from monolateral hearing loss (13 slight/mild, 13 moderate, 1 severe and 1 profound) and 39 from bilateral hearing loss (1slight/mild, 19 moderate, 13 severe and 7 profound). Excluding 7 infants from the NICU, 60 of 37,562 infants had hearing loss (1.5%).

CONCLUSIONS

The monitoring of the UNHS in Sicily has allowed obtaining the data of individual centres, absent in the literature to date, to verify the effectiveness of the screening, according to JCIH criteria, to highlight some criticalities and, finally, to propose possible solutions.

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Status of early hearing detection and intervention in South Korea: a nationwide population-based study of national infant health checkup

The aim of this study was to evaluate the status of early hearing detection and intervention after newborn hearing screening (NHS) in South Korea. A retrospective review of Korean national health insurance service data of all infants receiving the 4-month old national infant health checkup between 2010 and 2016 from a nationwide population-based database was conducted. Based on the results of the NHS-administered hearing questionnaires as part of the national infant health checkup, individuals were classified into "pass" (1,730,615 infants) or "refer" (10,941 infants) groups. Next, an analysis was conducted of age and the frequencies of tracking audiologic tests and surgeries of the middle ear (ME) and cochlear implants (CI). Diagnostic auditory brainstem response and audiometry, and surgeries of ME and CI were significantly performed more and earlier in the refer group compared with the pass group. For infants in the pass group who were presumed to have delayed or acquired hearing loss, the time of the first audiology tests and CI surgery was significantly delayed compared to those in the refer group; the average ages for first CI were 37 and 52 months in the refer group and pass group, respectively. Therefore, for early detection of delayed-onset hearing loss, regular hearing screening programs should be considered throughout the preschool ages.

Global Regulatory Review Needed for Cochlear Implants: A Call for FDA Leadership

INTRODUCTION

Using the United States Food and Drug Administration (FDA) as example, we argue that regulatory agencies worldwide should review their guidance on cochlear implants (CIs).

METHODS

This is a position paper, thus the methods are strictly argumentation. Here we give the motivation for our recommendation. The FDA's original approval of implantation in prelingually deaf children was granted without full benefit of information on language acquisition, on childcaregiver communication, and on the lived experience of being deaf. The CI clinical trials, accordingly, did not address risks of linguistic deprivation, especially when the caregiver's communication is not fully accessible to the prelingually deaf child. Wide variability in the effectiveness of CIs since initial and updated approval has been indicated but has not led to new guidance. Children need to be exposed frequently and regularly to accessible natural language while their brains are still plastic enough to become fluent in any language. For the youngest infants, who are not yet producing anything that could be called language although they might be producing salient social signals (Goldstein et al. Child Dev 80:636-644, 2009), good comprehension of communication from caregiver to infant is critical to the development of language. Sign languages are accessible natural languages that, because they are visual, allow full immersion for deaf infants, and they supply the necessary support for this comprehension. The main language contributor to health outcomes is this combination of natural visual language and comprehension in communication. Accordingly, in order to prevent possible language deprivation, all prelingually deaf children should be exposed to both sign and spoken languages when their auditory status is detected, with sign language being critical during infancy and early childhood. Additionally, all caregivers should be given support to learn a sign language if it is new to them so that they can comprehend their deaf children's language expressions fully. However, both languages should be made accessible in their own right, not combined in a simultaneous or total communication approach since speaking one language and signing the other at the same time is problematic.

RESULTS

Again, because this is a position paper, our results are our recommendations. We call for the FDA (and similar agencies in other countries) to review its approval of cochlear implantation in prelingually deaf children who are within the sensitive period for language acquisition. In the meantime, the FDA should require manufacturers to add a highlighted warning to the effect that results with CI vary widely and CIs should not be relied upon to provide adequate auditory input for complete language development in all deaf children. Recent best information on users' experience with CIs (including abandonment) should be clearly provided so that informed decisions can be made. The FDA should require manufacturers' guidance and information materials to include encouragement to parents of deaf children to offer auditory input of a spoken language and visual input of a sign language and to have their child followed closely from birth by developmental specialists in language and cognition. In this way parents can align with providers to prioritize cognitive development and language access in both audio-vocal and visuo-gestural modalities.

DISCUSSION

The arguments and recommendations in this paper are discussed at length as they come up.

Analysis of the effectiveness of coupon-mediated newborn hearing screening program through comparison of two government-funded pilot projects in South Korea

OBJECTIVE

The aims of this study are to compare the results of two government-funded newborn hearing screening (NHS) pilot programs and evaluate the feasibility and the effectiveness of the coupon-mediated NHS program in Korea.

METHODS

We retrospectively analyzed the database of the NHS center of the Ministry of Health and Welfare (MHW) from 2007 to 2013. Before the NHS was covered by national health insurance in 2018, the MHW conducted two types of NHS pilot programs. For the first pilot program, the MHW initiated an area based universal newborn hearing screening (UNHS) program which initially included 16 in 2007 and then spreading to 32 administrative areas in 2008 for all newborns in the pilot areas regardless of income level. The second pilot program was an offshoot of the continuing expansion of the first pilot program, which was a nationwide coupon-mediated NHS program for low-income families from 2009. The hearing loss (HL) was defined as a threshold of 40 dB nHL or worse on the auditory brainstem response (ABR) test. In both NHS pilot programs, the government financially supported the cost of the first NHS test and one ABR test for an infant who did not pass NHS test.

RESULTS

During the 1st NHS pilot program, 29.8% of the target neonates were screened which was 3.9% of total births; during the 2nd NHS pilot program 81.1% of the target neonates were screened which was 8.8% of total births. Documented diagnostic ABR tests were performed in 12.4% of referred infants in the 1st program and 33.5% in the 2nd program. The prevalence of HL was 0.11% in the 1st program and 0.15% in the 2nd program. In the 2nd NHS coupon-mediated program, the NHS was performed on average 5.4 ± 8.7 days after birth, and the diagnostic ABR test in the referred infants were performed on 61.3 ± 45.0 days after birth. There was no comparable recorded data in the 1st NHS pilot program.

CONCLUSIONS

This study suggests that the coupon-mediated NHS pilot program may be a worthwhile government-led NHS project for the proper tracking and accurate statistics. This program helped formulate UNHS national health insurance policies. However, to become a successful UNHS program, the governmental supports for both timely interventions and the inauguration of a web tracking system are mandatory.

Results of a Government-supported Newborn Hearing Screening Pilot Project in the 17 Cities and Provinces from 2014 to 2018 in Korea

BACKGROUND

The aim of this study was to present and analyze, for the first time, the results of a government-supported nationwide newborn hearing screening (NHS) pilot project in the 17 major cities and provinces of Korea.

METHODS

We analyzed a nationwide NHS database of 344,955 newborns in the pilot project from 2014 to 2018. The government supported the cost of one NHS and one diagnostic auditory brainstem response (ABR) test. Hearing loss (HL) was defined as ≥ 40 dB nHL on either side of the ABR threshold test.

RESULTS

Most NHS tests were performed in the maternity clinics (91.5%). In regions with lack of maternity clinics, the screening rate of local clinics was high (Jeju: 31.1% and Sejong: 12.9%). In most regions, automated ABR was mainly used for screening test (89.7%), but Gangwon (32.7%), Jeju (31.0%), and Jeonbuk (29.6%) performed more NHS tests using (automated) otoacoustic emissions than other regions. The mean referral rate was 1.5%, but the overall diagnostic ABR rate was low at 18.5%. The referral rates of Busan (0.6%) and Gyeongnam (0.9%) were lower than 1%, and Jeju's referral rate was 7.3%. Prevalence of HL including unilateral HL was 0.12%.

CONCLUSION

Depending on the cities and provinces, there were significant differences in the screening rates and referral rates by hospital type and NHS method. For successful early hearing detection and intervention (EHDI) and quality control, it will be necessary to support and manage EHDI according to regional NHS's characteristics and ensure that the whole country conducts EHDI as standard.

The Input Matters: Assessing Cumulative Language Access in Deaf and Hard of Hearing Individuals and Populations

Deaf and hard-of-hearing (DHH) children present several challenges to traditional methods of language assessment, and yet language assessment for this population is absolutely essential for optimizing their developmental potential. Whereas assessment often focuses on language outcomes, this Conceptual Analysis argues that assessing cumulative language input is critically important both in clinical work with DHH individuals and in research/public health contexts concerned with DHH populations. At the individual level, paying attention to the input (and the person's access to it) is vital for discriminating disorder from delay, and for setting goals and strategies for reaching them. At the population level, understanding relationships between cumulative language input and resulting language outcomes is essential to the broader public health efforts aimed at identifying strategies to improve outcomes in DHH populations and to theoretical efforts to understand the role that language plays in child development. Unfortunately, several factors jointly result in DHH children's input being under-described at both individual and population levels: for example, overly simplistic ways of classifying input, and the lack of tools for assessing input more thoroughly. To address these limitations, this Conceptual Analysis proposes a new way of characterizing a DHH child's cumulative experience with input, and outlines the features that a tool would need to have in order to measure this alternative construct.

Comparison of newborn hearing screening results between well babies and neonates admitted to the neonatal intensive care unit for more than 5 days: Analysis based on the national database in Korea for 9 years

Objective

The purpose of this cohort study is to compare newborn hearing screening (NHS) results between healthy newborns and neonates who were admitted to the neonate intensive care unit (NICU) for more than 5 days based on the national database for 9 years. Ultimately, we’ve tried to analyze the associated factors necessary to manage the national NHS program according to the group, which would help to establish policy to effectively detect and support hearing impaired children and which would help to control qualities.

Methods

The Ministry of Health and Welfare (MHW) introduced a nationwide coupon-mediated program for the low-income class since 2009. The coupon consisted of two parts, the screening part and the confirming parts with the same unique number, and the MHW supported the cost of one screening test and one diagnostic auditory brainstem response (ABR) test for infants who did not pass from the screening test. We have analyzed the screening test performing rate, the referral rate according to the screening methods or institutions, the prevalence of hearing loss, and the average age of hearing loss diagnosis. Hearing loss was defined as any hearing impairment either unilateral or bilateral with the hearing threshold ≥ 40 dB nHL on the diagnostic ABR test, irrespective of its etiology.

Results

A total of 524,371 newborns were enrolled in the study, and 506,634 (96.6%) neonates were in the “well-baby group (WBG)”, while 17,737 (3.4%) were in the “high-risk group (HRG)”. The referral rate of the screening test was 1.5% in average, 1.3% in the WBG, and 7.5% in the HRG. The referral rates varied according to the screening methods and screening institutions. The adjusted prevalence of HL was 5.6/1,000 in average, 4.6/1,000 in the WBC, and 28.8/1,000 in the HRG. The screening tests were performed 4.3 ± 6.7 days after birth and the diagnostic tests were done 62.7 ± 37.5 days after birth in WBG. In HRG, dates were 17.7 ± 19.3 days and 97.6 ± 51.4 days, respectively.

Conclusions

The prevalence of hearing loss in infants who were hospitalized in NICU for more than 5 days was about seven times higher than that in healthy newborns. However, different referral rates were noted depending on both institutions and the screening methods. These differences need to be addressed in order to improve our program and ensure that all neonates with hearing loss, especially neonates with high risk factor, are detected and appropriately referred for the treatment.

Hearing and communicative skills in the first years of life in children with congenital Zika syndrome

INTRODUCTION

Microcephaly is recognized as one of the main consequences of congenital Zika syndrome, but other serious problems such as global hypertonia, irritability, excessive crying, swallowing disorders, seizures, visual impairment and sensorineural hearing loss have been identified as associated with the syndrome.

OBJECTIVE

Describe the developmental characteristics of hearing and language skills in the first year of life of children with normal hearing thresholds' and congenital Zika syndrome.

METHODS

This is a cross-sectional study that evaluated hearing and language skills in the first year of life of 88 children with normal peripheral hearing and confirmed congenital Zika syndrome. All children were submitted to a behavioral auditory test and a validated questionnaire addressed to parents or caregivers, which was used as an instrument for assessing hearing and communicative skills.

RESULTS

The delay in communicative skills was present in 87.5% of the children, while 44.3% of them demonstrated a delay in hearing acuity. Only the alteration of cervical motor control presented as a statistically significant association with delays in both skills (p-value=0.006 and <0.001 for hearing and communicative skills, respectively), while the presence of microcephaly and the degree of its severity were only associated with delayed development of communicative skills.

CONCLUSION

Despite a normal peripheral auditory system, children with congenital Zika syndrome may demonstrate delayed language development by having neurological damage at the center of auditory processing, requiring more specific studies to clarify language acquisition in this population.

Etiology of newborn hearing impairment in Guangdong province: 10-year experience with screening, diagnosis, and follow-up

BACKGROUND

Hearing impairment is one of the most common birth defects in children. Universal newborn hearing screenings have been performed for 19 years in Guangdong province, China. A screening/diagnosis/intervention system has gradually been put in place. Over the past 10 years, a relatively complete data management system had been established. In the present study, an etiological analysis of newborn cases that failed the initial and follow-up screenings was performed.

METHODS

The nature and degree of hearing impairment in newborns were confirmed by a set of procedures performed at the time of initial hearing screening, rescreening and final hearing diagnosis. Then, multiple examinations were performed to explore the associated etiology.

RESULTS

Over a period of 10 years, 720 children were diagnosed with newborn hearing loss. Among these children, 445 (61.81%) children had a clearly identified cause, which included genetic factor(s) (30.56%), secretory otitis media (13.30%), maternal rubella virus infection during pregnancy (5.83%), inner ear malformations (4.86%), maternal human cytomegalovirus infection during pregnancy (2.92%), malformation of the middle ear ossicular chain (2.50%) and auditory neuropathy (1.81%). In addition, 275 cases of sensorineural hearing loss of unknown etiology accounted for 38.19% of the children surveyed.

CONCLUSIONS

Long-term follow-up is needed to detect delayed hearing impairment and auditory development in children. The need for long-term follow-up should be taken into account when designing an intervention strategy. Furthermore, the use of the deafness gene chip should further elucidate the etiology of neonatal hearing impairment.

Adherence to follow-up recommendations for babies at risk for pediatric hearing loss

OBJECTIVE

The purpose of this retrospective study was to evaluate the families' compliance with recommendations for continued monitoring of babies with high-risk factors for hearing loss.

METHODS

Hearing screening and follow-up results from 604 babies were tracked across a five-year period. Bivariate analysis, including chi-square analysis, t-tests, and one-way analyses of variance were conducted to test whether various factors predicted likelihood of follow up.

RESULTS

Although 86% of the babies returned for the initial follow-up appointment, few completed the protocol or were diagnosed with hearing loss (10.3%). Excluding the babies who never returned, the average age for initial assessment was near the recommended 3-month target (3.5 months). However, babies were last seen at 9.4 months on average, which is earlier than recommended. Some factors positively predicted follow-up: receipt of ototoxic medication, hyperbilirubinemia requiring transfusion, ECMO, syndromes associated with hearing loss, craniofacial anomalies, and passing the newborn hearing screening. Others were negatively predictive: NICU stay >5 days, younger maternal age, and failing the newborn screening. There was no relationship between the results of the last test and whether the families continued with monitoring. Babies with risks categorized as more likely to be associated with delayed onset hearing loss were more often late to the initial follow up, but also followed up for a longer period of time.

CONCLUSIONS

These results demonstrate the need to focus on the barriers unique to babies with risk factors for late onset/progressive hearing loss in addition to those barriers that generally affect loss to follow up. Tools for parental engagement are recommended.

From Neonatal Hearing Screening to Intervention: Results of the Dutch Program for Neonatal Hearing Screening in Well Babies

In the Netherlands, Youth Health Care services (YHC) have been carrying out neonatal hearing screening (NHS) in newborns since 2006. The aim of the NHS is to identify children with permanent hearing loss, so that intervention can be started before the age of 4 months. Early detection of hearing loss is important, as children who start intervention early have been shown to develop better. This article describes the structure and performance of the NHS carried out by the YHC, the quality of the program, and the timeliness of the start of intervention. Since its implementation, the NHS has been audited annually in order to monitor the program's quality. Monitoring reports and data from the Dutch Foundation for the Deaf and Hard of Hearing Child were used in this study. For many years, results have shown the NHS to be a stable screening program of high quality. The participation rate is high, refer percentage low, and the timeliness of the program is continually improving. Although the timeliness of post screening diagnostics and intervention need most improvement as they do not always meet the target times, this has improved over recent years.

The Yoruba version of LittlEARS Auditory Questionnaire: Evaluation of auditory development in children with normal hearing

The goal of this study was to translate the LittlEARS Auditory Questionnaire into Yoruba language for use with Yoruba-speaking parents and to evaluate the psychometric properties of the Yoruba version of questionnaire. Translation of the LittlEARS Auditory Questionnaire into Yoruba language was done using a back-translation method. The study participants included 423 parents of normal hearing children aged 6-24 months. Psychometric analyses (scale analysis and item analysis) of the translated questionnaire was done. The scale characteristics in the dataset are: Internal consistency: Cronbach's alpha = 0.907; reliability; Split-half = 0.701; predictive accuracy; Guttman's lambda = 0.583; correlation between total score and children's age = 0.783. The regression analysis showed that 75.3% of the variance in the total scores can be explained by age. The Yoruba version of the LittlEARS Auditory Questionnaire is a dependable and valid tool as evidenced by the results of psychometric analyses. The tool is useful for assessing auditory development in children between 6 and 24 months of age.

A Qualitative Study on Knowledge and Attitude towards Risk Factors, Early Identification and Intervention of Infant Hearing Loss among Puerperal Mothers- A Short Survey

INTRODUCTION

Maternal active participation and their support are critical for the success of early hearing loss detection program. Erroneous maternal decisions may have large life long consequences on the infant's life. The mothers' knowledge and their attitudes towards infant hearing loss is the basis for their decisions.

AIM

The present study was done to determine the mothers' knowledge and their attitude towards risk factors of infant hearing loss, its early identification and intervention and also awareness of effect of consanguinity on hearing loss.

MATERIALS AND METHODS

In this cross-sectional questionnaire survey study, a total of 100 mothers were interviewed using the questionnaire which consisted of three sections namely risk factors, early identification and early intervention of hearing loss. Chi-square test was used to establish relationship between consanguineous and non-consanguineous mother's responses to its effect on hearing loss. A p-value < 0.05 was considered as significant.

RESULTS

Mothers' awareness was significantly high for visible causes (ear pain/discharge, head injury and slap to ear) of hearing loss. Positive attitude was seen for importance of screening programs and follow up testing. Moderate level of awareness was found on hazards of consanguinity and benefits of early identification. However, mothers were least aware of neonatal jaundice, NICU admission (>5 days), signs of late-onset and neural hearing loss, management of hearing loss, hearing aid fitting and therapy necessity, which might interfere in early detection and intervention of hearing loss.

CONCLUSION

It is crucial to educate mothers on few risk factors and management of hearing loss to reduce its consequences.

Streptococcus pneumoniae Otitis Media Pathogenesis and How It Informs Our Understanding of Vaccine Strategies

PURPOSE OF REVIEW

This study aimed to review the literature regarding the mechanisms of transition from asymptomatic colonization to induction of otitis media and how the insight into the pathogenesis of otitis media has the potential to help design future otitis media-directed vaccines.

RECENT FINDINGS

Respiratory viruses have long been shown to predispose individuals to bacterial respiratory infections, such as otitis media. Recent information suggests that Streptococcus pneumoniae, which colonize the nasopharynx asymptomatically, can sense potentially "threatening" changes in the nasopharyngeal environment caused by virus infection by upregulating specific sets of genes involved in biofilm release, dissemination from the nasopharynx to other sites, and protection against the host immune system. Furthermore, an understanding of the transcriptional and proteomic changes occurring in bacteria during transition to infection has led to identification of novel vaccine targets that are disease-specific and will not affect asymptomatic colonization. This approach will avoid major changes in the delicate balance of microorganisms in the respiratory tract microbiome due to elimination of S. pneumoniae.

SUMMARY

Our recent findings are reviewed in the context of the current literature on the epidemiology and pathogenesis of otitis media. We also discuss how other otopathogens, such as Haemophilus influenzae and Moraxella catarrhalis, as well as the normal respiratory microbiome, can modulate the ability of pneumococci to cause infection. Furthermore, the unsatisfactory protection offered by the pneumococcal conjugate vaccines is highlighted and we review potential future strategies emerging to confer a more specific protection against otitis media.

Recovery of Abnormal ABR in Neonates and Infants at Risk of Hearing Loss

The purpose of this retrospective study is to present the clinical experience of a single institution on the recovery of ABR thresholds in a large population of neonates and infants at risk of hearing loss. Potential prognostic factors associated with this phenomenon were also investigated. Out of 2248 high risk infants, 384 had abnormal ABR at initial hearing evaluation and 168 of them had absent ABR or a threshold ≥80 dBnHL. From this subgroup, a significant percentage showed complete or partial recovery on reexamination (32.7% and 9.3%, resp.), performed 4-6 months later. The presence of normal otoacoustic emissions was associated with the ABR restoration on reexamination. Moreover, the very young age at the initial hearing screening seems to be related to higher probabilities of false positive ABR. The potential recovery of hearing in HR infants raises concerns about the very early cochlear implantation in HR infants less than one year. Such a treatment modality should be decided cautiously and only after obtaining valid and stable objective and subjective hearing thresholds. This holds especially true for infants showing an auditory neuropathy profile, as they presented a much greater probability of ABR recovery.

Evidence for a Right-Ear Advantage in Newborn Hearing Screening Results

The aim of the present study was to investigate the effect of ear asymmetry, order of testing, and gender on transient-evoked otoacoustic emission (TEOAE) pass rates and response levels in newborn hearing screening. The screening results of 879 newborns, of whom 387 (study group) passed screening successfully in only one ear in the first TEOAE screening, but passed screening successfully in both ears thereafter, and 492 (control group) who passed screening successfully in both ears in the first TEOAE, were retrospectively examined for pass rates and TEOAE characteristics. Results indicated a right-ear advantage, as manifested by significantly higher pass rates in the right ear (61% and 39% for right and left ears, respectively) in the study group, and in 1.75 dB greater TEOAE response amplitudes in the control group. The right-ear advantage was enhanced when the first tested ear was the right ear (76%). When the left ear was tested first, pass rates were comparable in both ears. The right-ear advantage in pass rates was similar in females versus males, but manifested in 1.5 dB higher response amplitudes in females compared with males, regardless of the tested ear and order of testing in both study and control groups. The study provides further evidence for the functional lateralization of the auditory system at the cochlear level already apparent soon after birth in both males and females. While order of testing plays a significant role in the asymmetry in pass rates, the innate right-ear advantage seems to be a more dominant contributor.

Clinical Practice Guideline: Otitis Media with Effusion

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline “Otitis Media With Effusion in Young Children,” which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology- Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline.

The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM).

The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown).

The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed.

The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed.

This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. (Otolaryngol Head Neck Surg 2004;130:S95.)

Population Outcomes of Three Approaches to Detection of Congenital Hearing Loss

BACKGROUND

Universal newborn hearing screening was implemented worldwide largely on modeled, not measured, long-term benefits. Comparative quantification of population benefits would justify its high cost.

METHODS

Natural experiment comparing 3 population approaches to detecting bilateral congenital hearing loss (>25 dB, better ear) in Australian states with similar demographics and services: (1) universal newborn hearing screening, New South Wales 2003-2005, n = 69; (2) Risk factor screening (neonatal intensive care screening + universal risk factor referral), Victoria 2003-2005, n = 65; and (3) largely opportunistic detection, Victoria 1991-1993, n = 86. Children in (1) and (2) were followed at age 5 to 6 years and in (3) at 7 to 8 years. Outcomes were compared between states using adjusted linear regression.

RESULTS

Children were diagnosed younger with universal than risk factor screening (adjusted mean difference -8.0 months, 95% confidence interval -12.3 to -3.7). For children without intellectual disability, moving from opportunistic to risk factor to universal screening incrementally improved age of diagnosis (22.5 vs 16.2 vs 8.1 months, P < .001), receptive (81.8 vs 83.0 vs 88.9, P = .05) and expressive (74.9 vs 80.7 vs 89.3, P < .001) language and receptive vocabulary (79.4 vs 83.8 vs 91.5, P < .001); these nonetheless remained well short of cognition (mean 103.4, SD 15.2). Behavior and health-related quality of life were unaffected.

CONCLUSIONS

With new randomized trials unlikely, this may represent the most definitive population-based evidence supporting universal newborn hearing screening. Although outperforming risk factor screening, school entry language still lagged cognitive abilities by nearly a SD. Prompt intervention and efficacy research are needed for children to reach their potential.

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.

A triagem auditiva neonatal na Rede Municipal do Rio de Janeiro, Brasil

A deficiência auditiva é doença prevalente e justifica a necessidade de regulamentação das Leis e suas execuções através das Portarias de Atenção à Saúde Auditiva. Diante das políticas públicas, as maternidades que estavam inseridas na rede iniciaram processo de implantação do serviço de Triagem Auditiva Neonatal (TAN), como ocorrido Município do Rio de Janeiro. Para TAN utiliza-se o exame de Emissões Otoacústicas por ser um método rápido, de alta fidedignidade, fácil execução, com resultados objetivos. O objetivo deste artigo é conhecer melhor a assistência e o cuidado à saúde auditiva dos RN nas maternidades da Rede Municipal de Saúde. Estudo observacional, descritivo, transversal, análise descritiva com distribuição de frequências, e teve como objeto as Maternidades da Secretaria Municipal de Saúde-RJ que realizavam TAN. Foram identificadas três maternidades com TAN (A, B e C). Nelas foram registrados 1.865 RN vivos. Destes, o total que realizou triagem foi de 40,5%. Nas maternidades A e B, 54,6% realizaram TAN e destes, 97,3% passaram na TAN e apenas 1,7% falharam e precisariam ser encaminhados para o serviço de alta complexidade. A TAN é o início do Programa de Atenção a Saúde Auditiva do RN. É importante que os serviços de TAN funcionem integrados à rede através do Programa de Atenção à Saúde Auditiva.

Newborn dried blood-spot screening of the p.V37I variant of GJB2 by high-resolution melting analysis

OBJECTIVES

To establish a high-throughput, low-cost method for neonatal genetic testing of the p.V37I of GJB2 gene, which is highly prevalent in East Asians and strongly associated with postnatal childhood hearing impairment.

METHODS

A total of 6460 newborn blood-spot DNA samples were screened by high-resolution melting analysis (HRMA).

RESULTS

The screening results were further verified by direct sequencing of 28 homozygous, 545 heterozygous and 200 wild-type samples.

CONCLUSION

Our study indicated that the HRMA-based bloodspot screening method was of very high sensitivity and specificity and was suitable for large-scale screening of the p.V37I variants in newborns.

Legislation impacting audiology and the provision of audiological services: a review of legislation across the United States

PURPOSE

The purpose of this review was to investigate the legislation about the provision of audiology services. Specifically, the goal of the review was to investigate the similarities and differences in legislation regarding the identification of, and audiology services provided to, children with hearing loss.

METHOD

A systematic review was conducted to collect state-specific legislation regarding the audiology licensure requirements, requirements about the identification and management of children with hearing loss, and insurance coverage regulations. Compiled data were analyzed for similarities and differences between state regulations and legislature.

RESULTS

All states require audiologists to hold licensure; however, many differences exist between the requirements of acquiring and maintaining the license. Some states regulate the identification and management of children with hearing loss, whereas others do not. Additionally, states differ in their regulation of services provided to children with hearing loss, who can provide these services, and what is covered by insurance.

CONCLUSION

It is critical for audiologists to understand the requirements of their state in the provision of audiology services. Specifically, it is important for audiologists to understand how the laws may impact the services they provide to children with hearing loss.

Testing time comparison between two procedures with new technologies of Automated Auditory Brainstem Response (AABR)

PURPOSE

To compare the testing time of two Automated Auditory Brainstem Response (AABR) procedures using different repetition rates and detection modes.

METHODS

A hearing screening using AABR was performed in 30 newborns with mean age of 21 days. Each newborn was submitted to two hearing screening procedures using different AABR equipments (Procedure 1 and Procedure 2). Procedure 1 used a repetition rate of 53 Hz and the one-sample test for response detection; Procedure 2 used a repetition rate of 90 Hz, and the q-sample test for response detection. The ABR with click stimulus was then registered as gold standard test, and the responses were analyzed by a trained audiologist.

RESULTS

The mean time observed for Procedure 1 considering both ears was 84.8 (±53.5) seconds; for Procedure 2 the mean time was 27.9 (±20.0) seconds. The testing time of the first procedure was three times longer than the second one. Statistical analysis showed significant difference between the testing times of the procedures.

CONCLUSION

The q-sample test and the repetition rate of 90 Hz used in the AABR equipment showed earlier response detection.

Factors influencing delayed presentation of congenitally hearing impaired children in rural India

A study was conducted to determine why there was a delay in detection of hearing loss in congenitally hearing impaired children in rural India. It was found that although the parents of these children visited a primary care physician, relevant information regarding investigation and rehabilitation of hearing loss was not available to the patient. In the absence of a universal hearing screening programme in this country, it is a matter of importance to strengthen this aspect of community otolaryngology in the undergraduate ENT programme. There is also a need for continuing medical education programmes for primary care physicians regarding available methods of investigation and rehabilitation for a hearing impaired person.

Assessment of the feasibility and coverage of a modified universal hearing screening protocol for use with newborn babies of migrant workers in Beijing

BACKGROUND

Although migrant workers account for the majority of newborns in Beijing, their children are less likely to undergo appropriate universal newborn hearing screening/rescreening (UNHS) than newborns of local non-migrant residents. We hypothesised that this was at least in part due to the inadequacy of the UNHS protocol currently employed for newborn babies, and therefore aimed to modify the protocol to specifically reflect the needs of the migrant population.

METHODS

A total of 10,983 healthy babies born to migrant mothers between January 2007 and December 2009 at a Beijing public hospital were investigated for hearing abnormalities according to a modified UNHS protocol. This incorporated two additional/optional otoacoustic emissions (OAE) tests at 24-48 hours and 2 months after birth. Infants not passing a screening test were referred to the next test, until any hearing loss was confirmed by the auditory brainstem response (ABR) test.

RESULTS

A total of 98.91% (10983/11104) of all newborn children underwent the initial OAE test, of which 27.22% (2990/10983) failed the test. 1712 of the failed babies underwent the second inpatient OAE test, with739 failing again; thus significantly decreasing the overall positive rate for abnormal hearing from 27.22% to 18.36% ([2990-973 /10983)]; p = 0). Overall, 1147(56.87%) babies underwent the outpatient OAE test again after1-month, of whom 228 failed and were referred for the second outpatient OAE test (i.e. 2.08% (228/10983) referral rate at 1month of age). 141 of these infants underwent the referral test, of whom 103 (73.05%) tested positive again and were referred for a final ABR test for hearing loss (i.e. final referral rate of 1.73% ([228-38/10983] at 2 months of age). Only 54 infants attended the ABR test and 35 (0.32% of the original cohort tested) were diagnosed with abnormal hearing.

CONCLUSIONS

Our study shows that it is feasible and practical to achieve high coverage rates for screening hearing loss and decrease the referral rates in newborn babies of migrant workers, using a modification of the currently employed UNHS protocol.

Failure of hearing screening in high-risk neonates does not increase parental anxiety

OBJECTIVE

The aim of this study was to determine whether a failure of neonatal hearing screening affected the anxiety level of parents of high-risk infants.

METHODS

Two hundred and eighty-eight parents of infants included in the neonatal hearing screening protocol of our Institution were tested with the Spielberger State-Trait Anxiety Inventory and with an open-question questionnaire investigating parents' attitude to hearing problems in their child, done at the time of audiological follow-up. 105 were parents of high-risk infants who had been discharged from neonatal intensive care unit (NICU) and 183 of low-risk infants discharged from well-baby nursery.

RESULTS

No differences in anxiety levels were seen between parents of high-risk infants passing and failing neonatal hearing screening using homogeneous case-control pairs. Additionally, no differences in the level of anxiety were found between parents of high- and low-risk infants failing neonatal auditory screening.

CONCLUSIONS

Failure of neonatal auditory screening does not affect the anxiety levels of parents of high-risk infants at post discharge from NICU. This finding is a key factor to be considered when evaluating the costs and benefits of tests for universal neonatal hearing screening.

Monitoramento de crianças com indicadores de risco para a deficiência auditiva

OBJETIVO: descrever uma proposta de monitoramento de crianças, no primeiro ano de vida, que não foram identificadas na triagem auditiva neonatal, mas apresentavam indicadores de risco para deficiência auditiva. MÉTODO: participaram do estudo 258 crianças de risco que haviam obtido o resultado "passa" no Programa de Triagem Auditiva Neonatal Universal da Maternidade Santa Isabel - Bauru/SP no período de junho a novembro de 2008. Foi aplicado, via telefone, um questionário de acompanhamento do desenvolvimento da audição e da linguagem, validado em estudo anterior, contendo questões sobre a audição e a linguagem. Para cada questão havia duas possibilidades de resposta "sim" ou "não" e considerou-se como "falha", a obtenção de pelo menos uma resposta "não". Tal resultado refletia no agendamento da criança para realização de uma avaliação audiológica imediata. RESULTADOS: o questionário foi aplicado com 169 famílias, com as demais não foi obtido contato. Deste total, 164 (97,04%) apresentaram resultado "passa" e cinco (2,96%) resultado "falha". Dentre as cinco crianças, apenas três compareceram para avaliação audiológica e destas, uma não apresentava alterações e duas apresentavam perda auditiva condutiva. Observou-se prevalências distintas entre os fatores de risco e não houve relação (p>0,05) dos mesmos com a evasão no processo de monitoramento. CONCLUSÃO: o monitoramento por meio de aplicação de questionário via telefone mostrou-se viável, entretanto, é necessário o desenvolvimento de estratégias que favoreçam sua execução.

The potential risk factors and the identification of hearing loss in infants

To identify potential risk factors for hearing loss from the infant with high risk criteria as guided by the Joint Committee on Infant Hearing (JCIH, 2000). 490 infants with age range of 2 days to 6 months who had undergone detailed audiological evaluation during for the period of 3 years at Gauhati Medical College Hospital were taken for the study. The hearing screening was performed on each infant using Distortion Product Otoacoustic Emission (DPOAE) testing. The infants who failed DPOAEs screening were followed up and Auditory Brainstem Response testing. Out of 490 high risk infants who had undergone detailed audiological evaluation 145 infants were found to be having hearing loss. Out of 145 infants 73 infants were male and 72 infants were female. The risk factor for hearing loss with the highest incidence was hyperbilirubenemia, Apgar scores of 0-4 at 1 min or 0-6 at 5 min was the second most prevalent risk factor, followed by TORCH infections. This study suggests the need for review of high risk register that is used along with the physiological and electrophysiological hearing test to screen the infants. The high risk register remains helpful in determining follow up plans so that children who may develop late onset of hearing loss will not be missed. Being aware of which risk factors are more likely to cause hearing loss in infants would be helpful to plan for follow up these children.