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

Examining Barriers to Early Hearing Diagnosis

PURPOSE

Many factors create barriers for early hearing detection and intervention (EHDI), especially those related to unfavorable social determinants of health (SDOH). The primary aim of this study was to evaluate diagnostic timing of infants at risk for congenital hearing loss in consideration of known barriers. Understanding the specific barriers to early diagnosis can inform interventions to improve timeliness of diagnosis and subsequent habilitation.

METHOD

A retrospective chart review was completed for infants referred for diagnostic audiologic testing at a tertiary urban-setting Children's Hospital from 2018 to 2021. After exclusion criteria were applied, 1,488 infants were included in the analysis. Various factors were recorded from electronic medical records including those specific to SDOH. Time to diagnosis was derived and compared across five factors of interest that have previously been shown to impact diagnostic timeline, including (a) insurance type, (b) race/ethnicity, (c) presence of middle ear dysfunction at first auditory brainstem response (ABR), (d) proximity to diagnostic center, and (e) diagnostic timing before and during/after the COVID-19 pandemic.

RESULTS

Across the study time period, 77% of infants referred for diagnostic testing had confirmed diagnosis by the EHDI benchmark of 3 months. Analysis of time to diagnosis across factors of interest revealed no clinically significant differences for insurance type, race/ethnicity, proximity to diagnostic center, or timing in reference to the COVID-19 pandemic. Presence of middle ear dysfunction on first ABR was found to significantly protract final diagnostic timing.

CONCLUSIONS

Although some known barriers for EHDI can be universal, other factors may have a differential impact on an infant's timeline to diagnosis based on their specific location, which can interact differently with additional known barriers. Understanding local challenges will serve to better guide programs in implementing facilitators that will address their specific needs for improved outcomes.

Community Health Worker Intervention for Newborns Not Passing Initial Universal Hearing Screening

BACKGROUND

Universal newborn hearing screening (UNHS) is effective in identifying newborns with possible hearing loss (HL). Outpatient follow-up for newborns referred after hospital-based screening remains a potential area of improvement. In this study, we evaluate the efficacy of a community health worker (CHW) intervention in promoting adherence to outpatient rescreening for newborns referred after initial UNHS.

METHODS

A mixed prospective-retrospective cohort study was performed to evaluate a CHW intervention at an academic medical center. Caregivers of referred newborns were contacted by CHWs prior to discharge and educated about HL and the importance of follow-up screening. The CHW outreach intervention was performed for 297 referred newborns between May 2020 and June 2021 and compared to a cohort of 238 newborns without the CHW intervention between March 2019 and June 2021. Statistical analyses were conducted using 2 × 2 Chi-square tests, two-tailed unpaired t-tests, multinomial logistic regression, and multiple linear regression.

RESULTS

In the intervention group, 236 of 297 newborns (79.5%) completed their outpatient follow-up rescreening; in the comparison group, 170 of 238 newborns (71.4%) completed their follow-up rescreening (P = .031, OR = 1.55 with regression P = .04). In the intervention group, the average time to follow-up was 13.4 days versus 12.5 days for the comparison group (P = .449, multiple R2 = .02 with P = .78).

CONCLUSIONS

CHW outreach intervention may increase adherence to outpatient follow-up rescreening for newborns referred after initial, hospital-based UNHS. Expansion of nursery teams to include CHWs may thus improve completion of recommended follow-up hearing screens.

Socioeconomic Status and Cochlear Implant Usage: A Datalogging Study

OBJECTIVE

To evaluate the associations between proxy measures of socioeconomic status (SES) and usage of cochlear implants.

STUDY DESIGN

Retrospective case series.

METHODS

Usage outcomes were measured among patients with a cochlear implant and data logging at a tertiary care children's hospital between 2002 and 2017. Time per day with cochlear implant turned on, coil off, and listening to speech in noise and speech in quiet were extracted from audiology records, averaging right and left ear usage for those with bilateral implants. Associations between cochlear implant usage and demographic factors such as insurance type and median household income for zip code were assessed.

RESULTS

There were 142 total patients; 74 had bilateral usage data. Mean on air time was 10.76 hours (SD: 4.4). Those with private insurance had 1.2 hour more on air time/day (P = .047) and 0.9 hour more quiet time/day (P = .011) compared to those with public insurance. Younger age at last visit was associated with increased speech in quiet (B = -.08; 95% CI: -0.12-[-0.05], P < .001) and coil off (B = -0.06; 95% CI: -0.11-[-0.02], P = .006). Younger age at implant was associated with longer duration since last data logging visit (B = -10.46; 95% CI: -18.41-[-2.51], P = .010), more daily use (on air; B = -0.23; 95% CI: -0.43-[-0.03], P = .026), and increased time spent listening to speech in noise (B = -0.07; 95% CI: -0.14-[-0.01], P = .024). No other significant associations between datalogging output and each proxy SES factor were found.

CONCLUSIONS

Lack of private insurance and older age at implantation decreased access to binaural hearing for children and young adults with cochlear implants.

Conductive hearing loss in newborns: Hearing profile, risk factors, and occasions of service

OBJECTIVE

Infants diagnosed with a conductive hearing loss (CHL) are at increased risk of developmental delays. Using a sample of infants diagnosed with CHL through UNHS, this study aimed to investigate the relationship between specific demographic or clinical characteristics and 1) occasions of service to reach a hearing diagnosis and 2) the profile of CHL.

METHODS

Retrospective analysis was conducted for all infants with CHL born between 01/01/2007 and 31/12/2018 who had received UNHS. Chi squared analysis was conducted on data from 1208 records.

RESULTS

Infants with ≥1 risk factor for hearing loss were more likely to attend more than three occasions of service. Infants who were bilateral refer/medical exclusion, Torres Strait Islander, had ≥1 risk factors for hearing loss or were born pre-term had greater proportions of bilateral CHL than unilateral CHL. Mild to moderate was the most frequent degree of CHL, although a unilateral or bilateral CHL did not have an association with the severity of CHL. Compared to other risk factors, infants with a syndrome had greater proportions of bilateral than unilateral CHL. Risk factors of craniofacial abnormality, prolonged ventilation, or syndrome had greater proportions of mild to moderate CHL than moderate or greater. On average, infants were diagnosed with a CHL at 37.29 weeks of age.

CONCLUSION

These findings highlight the relationship between clinical/demographic characteristics and occasions of service to diagnose CHL in children, including the CHL profile. An understanding of this relationship may help clinicians to better plan, assess and manage infants diagnosed with a CHL through UNHS.

Do all infants with congenital hearing loss meet the 1-3-6 criteria? A study of a 10-year cohort from a universal newborn hearing screening programme in Singapore

OBJECTIVE

To evaluate 1) the outcomes of a local universal newborn hearing screening (UNHS) programme and its audiological follow-ups at 3- and 6-month points, 2) the education outcomes of children with congenital hearing loss (CHL).

DESIGN

Retrospective study that analysed data containing hearing screening, diagnosis, intervention and schooling information from electronic databases.

STUDY SAMPLE

Children aged 5 to 15 years old who were born between 2004-2014 and underwent UNHS in a local hospital.

RESULTS

Over a 10-year cohort, 99.4% of 29,972 newborns underwent UNHS; approximately 90% of them were screened by 1 month of age. However, only 10% of the cohort strictly fulfilled the 1-3-6 criteria recommended by the Joint Committee on Infant Hearing. Lost to follow-up (LTF) rate was highest at post-diagnosis (35%). 80% of infants who were intervened between 6 and 48 months of age went to mainstream schools. The remaining 20% had additional disabilities or family factors.

CONCLUSIONS

A high UNHS coverage rate may not translate to meeting the 1-3-6 criteria. Despite ease of access to our healthcare system, LTF at post-diagnosis remained high. In the absence of additional disabilities or family factors, infants intervened during the sensitive window could still potentially make it into mainstream schools.

Barriers to and Facilitators of Early Hearing Detection and Intervention in the United States: A Systematic Review

OBJECTIVES

Early hearing detection and intervention (EHDI) is guided by the 1-3-6 approach: screening by one month, diagnosis by 3 mo, and early intervention (EI) enrollment by 6 mo. Although screening rates remain high, successful diagnosis and EI-enrollment lag in comparison. The aim of this systematic review is to critically examine and synthesize the barriers to and facilitators of EHDI that exist for families, as they navigate the journey of congenital hearing loss diagnosis and management in the United States. Understanding barriers across each and all stages is necessary for EHDI stakeholders to develop and test novel approaches which will effectively reduce barriers to early hearing healthcare.

DESIGN

A systematic literature search was completed in May and August 2021 for empirical articles focusing on screening, diagnosis, and EI of children with hearing loss. Two independent reviewers completed title and abstract screening, full-text review, data extraction, and quality assessments with a third independent reviewer establishing consensus at each stage. Data synthesis was completed using the Framework Analysis approach to categorize articles into EHDI journey timepoints and individual/family-level factors versus system-level factors.

RESULTS

Sixty-two studies were included in the narrative synthesis. Results revealed that both individual/family-level (e.g., economic stability, medical status of the infant including middle ear involvement) and system-level barriers (e.g., system-service capacity, provider knowledge, and program quality) hinder timely diagnosis and EI for congenital hearing loss. Specific social determinants of health were noted as barriers to effective EHDI; however, system-level facilitators such as care coordination, colocation of services, and family support programs have been shown to mitigate the negative impact of those sociodemographic factors.

CONCLUSIONS

Many barriers exist for families to obtain appropriate and timely EHDI for their children, but system-level changes could facilitate the process and contribute to long-term outcomes improvement. Limitations of this study include limited generalizability due to the heterogeneity of EHDI programs and an inability to ascertain factor interactions.

Clinical characteristics of infants identified with a conductive hearing loss through universal newborn hearing screening: A population-based sample

BACKGROUND

Universal Newborn Hearing Screening (UNHS) aims to identify infants born with a permanent hearing loss. However, many are also diagnosed with a conductive hearing loss (CHL) and are at subsequent risk for developmental delays. The aim of this study was to investigate the prevalence of CHL and determine which clinical characteristics collected at birth, predict CHL within UNHS.

MATERIALS AND METHODS

Retrospective analysis was conducted on all infants born between January 01, 2007 and December 31, 2018. During this period, 731,234 infants were screened, 9802 were direct referrals, and 1208 identified with a CHL. Chi squared analysis and logistic regression was conducted to determine CHL prevalence and identify which clinical characteristics predict CHL.

RESULTS

The prevalence of CHL was 12.32%. Following adjustments for collinearity, clinical characteristics that could predict CHL were: bilateral referrals/medical exclusions to screen (Odds ratio, OR 1.89; 95% CI: 1.65-2.1), ≥1 risk factor for hearing loss (OR 2.03; 95% CI: 1.76-2.34), pre-term birth (OR 1.82; 95% CI: 1.57-2.10), male (OR 1.21; 95% CI: 1.07-1.37), and Indigenous status: 'Aboriginal (not Torres Strait Islander)' (OR 1.27; 95% CI:1.03-1.57 and 'not stated' (OR 2.95; 95% CI: 2.02-4.30).

CONCLUSION

CHL within UNHS was highly prevalent, with six clinical characteristics that can predict that likelihood of an infant being diagnosed with a CHL. This data could be used to create alternative care pathways for infants with CHL, enabling early and targeted assessments, thereby reducing the risk of developmental delays for these infants.

Pediatric Amplification: A Proposed Protocol for In-Person Hearing Aid Fittings and Virtual Follow-Ups

BACKGROUND

Children with hearing loss and their families face many financial and logistical barriers to accessing audiological care. At Rush University's Student Community Outreach Program of Excellence (SCOPE), a pediatric hearing loss outreach program is under development to address and overcome those barriers through in-person hearing aid fittings and virtual follow-up appointments.

OBJECTIVES

The goal of this clinical focus article was to develop a proposed protocol for SCOPE's pediatric hearing loss outreach program that would detail the use of a bimodal model of service delivery for pediatric amplification services. This clinical focus article provides a general description of the proposed protocol.

METHOD

The proposed protocol was developed as a guideline for future service delivery within SCOPE's pediatric hearing loss outreach program. Categories and details within the protocol were derived from previously published protocols and clinically relevant research.

RESULTS

The final protocol is composed of six sections, which detail the rationale and target population, necessary equipment, procedures for in-person hearing aid fittings, procedures for virtual follow-ups, outcome measures, and schedule of appointments.

DISCUSSION

On the national level, access to audiological care for pediatric patients and their families is restricted by both financial and logistical barriers. A telehealth model of service delivery has been shown to be effective in providing high-quality patient care while addressing these barriers. A clinical program using a bimodal model of service delivery will be implemented to address these barriers in Chicago, Illinois. Future investigation is required to monitor the efficacy of the program and develop program-specific materials.

Follow-up on children with suspected bilateral congenital hearing loss identified through universal newborn hearing screening program in Taiwan: A national-based population study

OBJECTIVE

This investigation was to ascertain the performance of the UNHS in Taiwan.

METHODS

The predefined questionnaire was delivered on the phone in 2016. The descriptive analysis was applied to the research data. 941 neonates in birth cohorts 2013-2014 who were documented as a bilateral referral in the national UNHS tracking system were targeted. The respondents were either caregivers or family members.

RESULTS

40.3% of 941 children were lost to follow-up, and 66.24% of 363 children were diagnosed with SNHL. 45.15% of 163 children used hearing amplification device(s). 77.46% of hearing amplification device users and 7.51% of non-users participated in the auditory training courses. By six months of age, 38.51% and 22.58% of children diagnosed with bilateral SNHL commenced the hearing amplification device fitting and the auditory training courses, respectively.

CONCLUSIONS

More efforts are needed to enhance the performance of the UNHS to achieve national goals stated in the 2014 Taiwan UNHS Revised Guidelines and the well-known benchmarks set by the JCIH in 2007. The development of an electronic tracking system for storing and sharing information on the follow-up on children with congenital hearing loss was as significant as the improvements in the understanding of early hearing detection and intervention of the public and stakeholders.

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.

Relationship between Behavioral Infant Speech Perception and Hearing Age for Children with Hearing Loss

(1) Background: Research has demonstrated that early intervention for children who are hard-of-hearing (CHH) facilitates improved language development. Early speech perception abilities may impact CHH outcomes and guide future intervention. The objective of this study was to examine the use of a conditioned head turn (CHT) task as a measure of speech discrimination in CHH using a clinically feasible protocol. (2) Methods: Speech perception was assessed for a consonant and vowel contrast among 57 CHH and 70 children with normal hearing (CNH) aged 5–17 months using a CHT paradigm. (3) Results: Regardless of hearing status, 74% of CHH and 77% of CNH could discriminate /a-i/, and 55% of CHH and 56% of CNH could discriminate /ba-da/. Regression models revealed that both CHH and CNH performed better on /ba-da/ at 70 dBA compared to 50 dBA. Performance by hearing age showed no speech perception differences for CNH and children with mild hearing loss for either contrast. However, children with hearing losses ≥ 41 dB HL performed significantly poorer than CNH for /a-i/. (4) Conclusions: This study demonstrates the clinical feasibility of assessing early speech perception in infants with hearing loss and replicates previous findings of speech perception abilities among CHH and CNH.

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.

Identification of Potential Barriers to Timely Access to Pediatric Hearing Aids

Importance

Despite various barriers identified to early pediatric access to cochlear implantation, barriers to timely access to pediatric hearing aids are not well characterized.

Objective

To identify socioeconomic, demographic, and clinical factors that may be associated with pediatric access to hearing aids.

Design, Setting, and Participants

This retrospective cohort study included 90 patients aged 1 to 15 years who were referred for auditory brainstem response (ABR) testing and evaluation for hearing aids at a single tertiary care academic medical center from March 2004 to July 2018. Children who did not receive both ABR testing and hearing aids at the same center were excluded from analysis.

Main Outcomes and Measures

Associations of insurance type (private vs public), race/ethnicity (white vs other), primary language (English vs other), cause of hearing loss (complex vs not complex), zip code, hearing aid manufacturer, and severity of hearing loss (in decibels) with the duration of intervals from newborn hearing screening to ABR testing, from ABR testing to ordering of hearing aids, and from ABR testing to dispensing of hearing aids.

Results

Of the 90 patients, mean (SD) age was 5.6 (3.7) years, 56% were female, and 77 (86%) were non-Hispanic. Results of χ2 tests indicated significant assocations existed between public insurance and race/ethnicity and between public insurance and primary language other than English. Variables associated with the interval from newborn hearing screening to ABR testing included insurance type (mean difference, 7.4 months; 95% CI, 2.6-12.2 months) and race/ethnicity (mean difference, 6.9 months; 95% CI, 2.7-11.1 months). Increased delays between birth and a child's first ABR test were associated with public insurance (mean difference, 6.0 months; 95% CI, 1.8-10.2 months) and race/ethnicity other than white (mean difference, 6.0 months; 95% CI, 2.3-9.7 months). The mean time from birth to initial ABR testing was a mean of 6 months longer for patients from non-English-speaking families than for those from English-speaking families (mean [SD] interval, 14.9 [16.3] months vs 9.0 [8.5] months), although the difference was not statistically significant. Severity of hearing loss was associated with a decrease in the interval from ABR testing to ordering of hearing aids after accounting for other potential barriers (odds ratio, 0.6; 95% CI, 0.4-0.9). Zip code and complexity of the child's medical condition did not appear to be associated with timely access to pediatric hearing aids.

Conclusions and Relevance

This study's findings suggest that insurance type, race/ethnicity, and primary language may be barriers associated with pediatric access to hearing aids, with the greatest difference observed in time to initial ABR testing. Clinical severity of hearing loss appeared to be associated with a significant decrease in time from ABR testing to ordering of hearing aids. Greater efforts to assist parents with ABR testing and coordination of follow-up may help improve access for other at-risk children.

Loss to Follow-Up After Newborn Hearing Screening: Analysis of Risk Factors at a Massachusetts Urban Safety-Net Hospital

OBJECTIVES

This study examines the unique factors that influence loss to follow-up after newborn hearing screening for patients at a Massachusetts urban safety-net hospital. We seek to characterize our patient population, investigate correlations between patient factors and rates of follow-up, and understand gaps in care.

DESIGN

A retrospective chart review was conducted of patients born at an urban safety-net hospital from January 2015 through May 2018 who did not pass the newborn hearing screening in one or both ears. A total of 197 infants were included in our study. Outcomes of interest included rates and latency of follow-up appointments, infant demographics (sex, race, birth weight, risk factors for hearing loss), and maternal factors (age, marital status, smoking status, number of children).

RESULTS

From January 2015 through May 2018, 17% (n = 34) of infants were lost to follow-up. Of those who attended an initial audiology evaluation, the median time between screening and appointment was 29 days. Newborns were 3.5 times at risk of being lost to follow-up if their mothers smoked during pregnancy compared to those whose mothers did not smoke. Further, newborns with multiple siblings in the home were less likely to utilize any audiological services. High-risk infants, such as those with an extended stay in the neonatal intensive care unit, were found to have higher rates of loss to follow-up.

CONCLUSIONS

Our results indicate that patients at urban safety-net hospitals require increased support to decrease rates of loss to follow-up. In particular, strategies to aid mothers who smoke, have multiple children, or have high-risk infants can address gaps in care for newborns after hearing screening.

Relationship between Insurance Type and Delays in Tympanostomy Tube Placement

OBJECTIVE

To investigate the role of insurance carriers and changes in insurance on rates of cancelation and rescheduling of tympanostomy tube surgery.

METHODS

Retrospective cohort study between January 1, 2013 and December 31, 2018 at a single tertiary care academic pediatric otolaryngology practice of pediatric patients (≤18 years) who underwent tympanostomy tube placement for any indication. Patients had to have insurance providers recorded both at clinic visit and at the time of surgery. Rates of cancelation and postponement of tympanostomy tube placement were assessed. Logistic regression was performed to determine factors associated with cancelation or postponement of surgery.

RESULTS

Of the 5080 patients, 2961 patients had Medicaid and 2012 patients had private insurance at the time of surgery. A total of 197 (3.96%) patients switched insurance between clinic appointment and date of surgery. Time to surgery was nearly 2 weeks more for those who had a change in insurance vs. those who did not (33 vs. 20 days, P < .001). Those who switched insurance were nearly twice as likely to have to reschedule surgery than those who did not (OR 1.95, CI 1.42-2.67). Patients who had Medicaid as the primary payer also had increased odds of needing to reschedule and postpone surgery (OR 1.39, 95% CI 1.17-1.63).

CONCLUSION

Difference in insurance carrier and loss/change of insurance appear to be associated with delays in tympanostomy tube placement. Standardization of re-enrollment schedules across insurance providers or a single payer model may be useful in addressing these delays in care.

Long-Term Otitis Media Outcomes in Infants With Early Tympanostomy Tubes

OBJECTIVE

To review the otologic outcomes of infants who failed the newborn hearing screen (NBHS) and received early tympanostomy tubes for otitis media with effusion (OME).

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

Consecutive patients (2007-2018) who failed an NBHS and required tympanostomy tubes before 6 months of age were included. Variables including hearing loss and otitis media risk factors, episodes of acute otitis media (AOM), number of subsequent tympanostomy tubes, and posttympanostomy tube audiogram results were recorded.

RESULTS

The cohort included 171 patients. Median age at referral to otolaryngology was 2.7 months. Sensorineural hearing loss (SNHL) was subsequently identified in 22 (12.9%) of infants after resolution of the effusion. The peak incidence of AOM was during the second year of life (1-1.9 years), with a median of 1 episode. Ninety-five patients (55.6%) had replacement of tubes, 41 of 171 (24.0%) had 2 or more additional sets of tubes, and long-term tubes were eventually placed in 8 of 95 (8.4%) patients. Craniofacial anomalies were identified in 43.3% of patients. Tube replacement (hazard ratio, 3.00; 95% CI, 1.95-4.63; P < .01, log-rank) and AOM (β, 1.04; 95% CI, 0.43-1.65; P = .04, ordered logistic regression) were more common, and SNHL less common (odds ratio, 0.17; 95% CI, 0.031-0.61; P < .01, logistic regression), in children with craniofacial anomalies.

CONCLUSION

OME is a common cause of failed NBHS. A notable proportion was subsequently found to have SNHL, reiterating the need for postoperative hearing assessments. Infants meeting indication for early tympanostomy tubes for resolution of OME have a high incidence of recurrent AOM and require subsequent tubes.

Age at onset of training in children with hearing and speech disorders and the analysis of related factors in Turkey

Background

Early diagnosis and intervention play a vital role in hearing and speech disorders and the effect of intervention varies according to the age at onset of training of children with such disorders. Aim of this study is to investigate the age at onset of training in children admitted to our center with complaints of hearing and speech disorder, and the related factors.

Methods

In the first phase of the study, data of 473 children admitted to our center between January 2015 and October 2018 with complaints of hearing and speech disorders and no additional disability were retrospectively analyzed. Then, their chronological age, gender, cause of admission, age at onset of training and the effect of factors that may have an impact on the age at onset of training were analyzed statistically. Study data were obtained from patient records.

Results

Of 473 children (350 males and 123 females) admitted to our training center with the complaints of hearing and speech disorders, 252 (53.3%) were presented with speech sound disorders, 90 (19.0%) with stuttering, 87 (18.4%) with delayed speech, 32 (6.8%) with hearing loss and 12 (2.5%) with other causes. Although there was a statistically significant difference between the age at onset of training and the factors; such as cause of admission, parental education level, employment status of the mother, occupation of the father, and socioeconomic status of the family (p < 0.05), no statistically significant difference was found between the age at onset of training and gender (p > 0.05).

Conclusions

The study revealed that children with hearing loss have the chance of early diagnosis thanks to neonatal hearing screening programs and that they commence their training until the age of 2, which is considered to be a critical period for language and speech development. However, it is an undeniable fact that we have not yet reached the ideal age for the commencement of training (6th month). Similarly, the age of diagnosis and initiation of training is delayed in children with speech disorders due to families’ delayed referral to the training centers.

Analysis of Amount and Style of Oral Interaction Related to Language Outcomes in Children With Hearing Loss: A Systematic Review (2006-2016)

Purpose This systematic review summarizes the evidence for differences in the amount of language input between children with and without hearing loss (HL). Of interest to this review is evaluating the associations between language input and language outcomes (receptive and expressive) in children with HL in order to enhance insight regarding what oral language input is associated with good communication outcomes. Method A systematic review was conducted using keywords in 3 electronic databases: Scopus, PubMed, and Google Scholar. Keywords were related to language input, language outcomes, and HL. Titles and abstracts were screened independently, and full-text manuscripts meeting inclusion criteria were extracted. An appraisal checklist was used to evaluate the methodological quality of studies as poor, good, or excellent. Results After removing duplicates, 1,545 study results were extracted, with 27 eligible for full-text review. After the appraisal, 8 studies were included in this systematic review. Differences in the amount of language input between children with and without HL were noted. Conversational exchanges, open-ended questions, expansions, recast, and parallel talk were positively associated with stronger receptive and expressive language scores. The quality of evidence was not assessed as excellent for any of the included studies. Conclusions This systematic review reveals low-level evidence from 8 studies that specific language inputs (amount and style) are optimal for oral language outcomes in children with HL. Limitations were identified as sample selection bias, lack of information on control of confounders and assessment protocols, and limited duration of observation/recordings. Future research should address these limitations.

Meeting the Joint Committee on Infant Hearing Standards in a Large Metropolitan Children's Hospital: Barriers and Next Steps

Purpose The aim of this study was to determine how a large metropolitan children's hospital's practices align with the Joint Committee on Infant Hearing (JCIH) 1-3-6 guidelines (diagnose hearing loss by 3 months of age, fitted with hearing aids within 1 month of diagnosis, and enroll in early intervention by 6 months of age) and examine variables that have impacted meeting these guidelines. This hospital is not a birthing hospital. Therefore, the first recommendation (hearing screen by 1 month of age) was not evaluated. Method One hundred forty-one auditory evoked potential evaluations for infants under the age of 6 months were reviewed for this study. Data were only gathered for infants identified with a bilateral hearing loss ( n = 34). The following was recorded: degree of hearing loss, number of diagnostic sessions over time, the percentage of infants who transitioned to hearing aid fittings, and the age at which JCIH benchmarks were accomplished. Results Sixty-two percent of infants were diagnosed with hearing loss by 3 months of age, 48% of infants were fitted with hearing aids by 4 months of age, and the average age of infants enrolled in early intervention was 4.58 months. Seventy percent of infants were fitted within 1 month of the diagnosis of hearing loss. The identified variables that led to the hearing aids being fitted greater than 1 month after the diagnosis are as follows: cancellations/missed appointments, middle ear involvement, and mild hearing loss. Conclusions Results of this internal audit revealed opportunities for growth in better meeting and exceeding JCIH recommendations of diagnosis by 3 months of age and hearing aid fitting within 1 month of diagnosis. Adjustments in the scheduling process and appointment options have been implemented in response to these results. Additional examination of why these recommendations are not being met and what can be done to achieve them is needed.

Using Propensity Score Matching to Address Clinical Questions: The Impact of Remote Microphone Systems on Language Outcomes in Children Who Are Hard of Hearing

Purpose Children who are hard of hearing (CHH) have restricted access to acoustic and linguistic information. Increased audibility provided by hearing aids influences language outcomes, but the benefits of hearing aids are often limited by acoustic factors and distance. Remote microphone (RM) systems further increase auditory access by reducing the negative consequences of these factors. The purpose of this article was to identify factors that influence likelihood of RM system receipt and to investigate the effects of RM systems in home settings on later language outcomes. We used propensity score matching to compare language outcomes between children with and without access to personal RM systems in home settings. This article provides a description of how and why to perform propensity score-matching analyses with clinical populations. Method Participants were 132 CHH. Through parent report, we identified children who received RM systems for home use by 4 years of age. Logistic regression was used to determine factors that predict likelihood of RM system receipt in home settings. Propensity score matching was conducted on a subgroup of 104 participants. Performance on language measures at age 5 years was compared across propensity-matched children who did and did not receive RMs for personal use. Results Likelihood of RM receipt was associated with degree of hearing loss, maternal education, and location (recruitment site). Comparisons between matched pairs of children with and without RM systems in early childhood indicated significantly better discourse skills for children whose families owned RM systems, but no significant differences for vocabulary or morphosyntax. Conclusion Results provide preliminary evidence that the provision of personal RM systems for preschool-age CHH enhances higher-level language skills. The propensity score-matching technique enabled us to use an observational, longitudinal data set to examine a question of clinical interest.

Linear Mixed-Model Analysis to Examine Longitudinal Trajectories in Vocabulary Depth and Breadth in Children Who Are Hard of Hearing

Purpose Children who are hard of hearing (CHH) tend to have reduced vocabularies compared to children with normal hearing (CNH). Prior research on vocabulary skills in children with hearing loss has focused primarily on their breadth of knowledge (how many words are known). Depth of vocabulary knowledge (how well words are known) is not well documented for CHH. The current study used linear mixed models (LMMs) to investigate growth trajectories of vocabulary depth and breadth in CHH relative to age-matched CNH. Method Participants for this study included 155 children (93 CHH, 62 CNH) enrolled in a longitudinal study. Examiners administered a standardized measure of vocabulary knowledge at ages 7, 8, and 9 years. We constructed multiple LMMs with fixed effects for group and age. The models included various combinations of random intercepts for subject and item and random slope for age. Results For depth, CHH showed significant and stable deficits compared to CNH over time. For breadth, CNH showed greater vocabulary breadth, but the group differences diminished with age. For CHH, higher aided audibility, age, and maternal educational level were associated with greater vocabulary breadth and depth. Age at hearing aid fitting was not. Conclusions A major advantage of using LMM is that it allowed us to cope with missing data points while still accounting for variability within and across participants. Assessment of both vocabulary breadth and depth may be useful in identifying school-age CHH who are at risk of delays in language outcomes.

Early hearing detection and intervention in South Africa: Exploring factors compromising service delivery as expressed by caregivers

AIM

The main aim of this study was to explore factors compromising early intervention (EI) service delivery to hearing impaired children in South Africa, as expressed by their caregivers.

METHODS

Within a qualitative survey design, a sample of 19 hearing impaired children's caregivers completed structured self-administered questionnaires on factors that they perceive compromise EI for their children. These caregivers included mothers, fathers, grandparents, and legal guardians or adoptive parents of children with hearing impairment. Descriptive analysis of the data was undertaken.

RESULTS

Findings indicated various factors compromising EI as reported by caregivers. These included limited availability of appropriate schools and health care facilities for their hearing impaired children; long distances between the few services that are available and the places of residence of the service users; significant costs linked to the services (such as medical expenses, boarding school facilities costs); limited skills and knowledge of professionals and teachers regarding hearing impairment; inconsistent and conflicting professional opinions about the child's diagnosis and treatment; as well as limited community awareness about hearing impairment along with services available for hearing impaired children.

CONCLUSION

These findings have important clinical, training, policy, and advocacy implications within the South African context; if both access to and success within the EI services will be successful.

Implementation and evaluation of a rural community-based pediatric hearing screening program integrating in-person and tele-diagnostic auditory brainstem response (ABR)

BACKGROUND

In an attempt to reach remote rural areas, this study explores a community-based, pediatric hearing screening program in villages, integrating two models of diagnostic ABR testing; one using a tele-medicine approach and the other a traditional in-person testing at a tertiary care hospital.

METHODS

Village health workers (VHWs) underwent a five day training program on conducting Distortion Product Oto Acoustic Emissions (DPOAE) screening and assisting in tele-ABR. VHWs conducted DPOAE screening in 91 villages and hamlets in two administrative units (blocks) of a district in South India. A two-step DPOAE screening was carried out by VHWs in the homes of infants and children under five years of age in the selected villages. Those with 'refer' results in 2nd screening were recommended for a follow-up diagnostic ABR testing in person (Group A) at the tertiary care hospital or via tele-medicine (Group B). The overall outcome of the community-based hearing screening program was analyzed with respect to coverage, refer rate, follow-up rate for 2nd screenings and diagnostic testing. A comparison of the outcomes of tele-versus in-person diagnostic ABR follow-up was carried out.

RESULTS

Six VHWs who fulfilled the post training evaluation criteria were recruited for the screening program. VHWs screened 1335 children in Group A and 1480 children in Group B. The refer rate for 2nd screening was very low (0.8%); the follow-up rate for 2nd screening was between 80 and 97% across the different age groups. Integration of tele-ABR resulted in 11% improvement in follow-up compared to in-person ABR at a tertiary care hospital.

CONCLUSIONS

Non-availability of audiologists and limited infrastructure in rural areas has prevented the establishment of large scale hearing screening programs. In existing programs, considerable challenges with respect to follow-up for diagnostic testing was reported, due to patients being submitted to traveling long distance to access services and potential wage losses during that time. In this program model, integration of a tele-ABR diagnostic follow-up improved follow-up in comparison to in-person follow-up. VHWs were successfully trained to conduct accurate screenings in rural communities. The very low refer rate, and improved follow-up rate reflect the success of this community-based hearing screening program.

Hearing Loss and Failed Newborn Hearing Screen

Hearing loss is the most common congenital defect. With early diagnosis and intervention, we are able to improve speech and language outcomes in this population. In this article, we discuss the implications of the newborn hearing screen, as well as diagnostic interventions, management, and intervention, and the increasing role of congenital cytomegalovirus screening.

The Efficacy of Preschool Developmental Indicators as a Screen for Early Primary School-Based Literacy Interventions

Literacy success lays the foundation for children's later educational, health, and well-being outcomes. Thus, early identification of literacy need is vital. Using data from New Zealand's national preschool health screening program for fiscal years 2010/2011-2014/2015, demographic and health variables from 255,090 children aged 4 years were related to whether they received a literacy intervention in early primary school. Overall, 20,652 (8.1%) children received an intervention. Time-to-event analysis revealed that all considered variables were significantly related to literacy intervention (all p < .01), but the full model lacked reasonable predictive power for population screening purposes (Harrell's c-statistic = .624; 95% CI [.618, .629]). Including more direct literacy measures in the national screening program is likely needed for improvement.

Infant, Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening

OBJECTIVE

Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening.

METHODS

We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screening from 2007 to 2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. Neonatal intensive care unit infants were excluded. Outcomes included documented completion of the follow-up NBHS and completion by 1 month. Data sources comprised the electronic birth record, infant hearing integrated data system, and NBHS coordinator survey. Data were analyzed by logistic regression.

RESULTS

A total of 13,904 newborns did not pass the newborn admission hearing screening from 2007 to 2012, and 11,422 (82%) had documentation of a completed follow-up screening. A total of 10,558 (76%) completed follow-up screening by 1 month. All 53 NBHS coordinators completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight, and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a rescreening fee was associated with completion of follow-up screening.

CONCLUSIONS

Low-income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.

Characterization of newborn hearing screening failures in multigestational births

OBJECTIVE

To define the rate and characterize the type of newborn hearing screening failures in multigestational births.

METHODS

Retrospective chart review of all multigestational births that occurred in a 10-year period (2002-2012) in which at least one newborn failed newborn hearing screening at two tertiary care hospitals in the Northwell Health System.

RESULTS

Out of 125,405 total births, we identified 2961 multigestational births, of which 59 (2.0%) newborns failed newborn hearing screening. None of their 66 twin/triplet siblings failed their newborn hearing screens. Of 43 newborns that returned for follow-up, 56.0% (24/43) had confirmed hearing loss, resulting in an overall rate of 0.81% in all multigestational newborns with hearing loss. Of 19 infants that passed repeat testing, two were judged to need myringotomy tube placement. Twenty-four infants had a confirmed hearing loss, 11 of which had sensorineural hearing loss (0.37%), and 13 with a conductive or mixed hearing loss (0.44%).

CONCLUSIONS

We identified a greater than expected risk of conductive hearing loss, not attributable to otitis media, than sensorineural hearing loss in this population. These observations are consistent with the increased risk of birth defects in multigestational births.

Exploring reasons for late identification of children with early-onset hearing loss

INTRODUCTION

Several studies have shown that early identification of childhood hearing loss leads to better language outcomes. However, delays in the confirmation of hearing loss persist even in the presence of well-established universal newborn hearing screening programs (UNHS). The objective of this population-based study was to document the proportion of children who experienced delayed confirmation of congenital and early onset hearing loss in a UNHS program in one region of Canada. The study also sought to determine the reasons for delayed confirmation of hearing loss in children.

METHODS

Population level data related to age of first assessment, age of identification and clinical characteristics were collected prospectively for all children identified through the UNHS program. We documented the number of children who experienced delay (defined as more than 3 months) from initial audiologic assessment to confirmation of hearing loss. A detailed chart review was subsequently performed to examine the reasons for delay to confirmation.

RESULTS

Of 418 children identified from 2003 to 2013, 182 (43.5%) presented with congenital or early onset hearing loss, of whom 30 (16.5%) experienced more than 3 months delay from initial audiologic assessment to confirmation of their hearing disorder. The median age of first assessment and confirmation of hearing loss for these 30 children was 3.7 months (IQR: 2.0, 7.6) and 13.8 months (IQR: 9.7, 26.1) respectively. Close examination of the factors related to delay to confirmation revealed that for the overwhelming majority of children, a constellation of factors contributed to late diagnosis. Several children (n = 22; 73.3%) presented with developmental/medical issues, 15 of whom also had middle ear dysfunction at assessment, and 9 of whom had documented family follow-up concerns. For the remaining eight children, additional reasons included ongoing middle ear dysfunction for five children, complicated by family follow-up concerns (n = 3) and mild hearing loss (n = 1) and the remaining three children had isolated reasons related to family follow-up (n = 1) or mild hearing loss (n = 2).

CONCLUSION

Despite the progress made in the early detection of pediatric hearing loss since UNHS, a substantial number of children referred for early assessment can experience late confirmation and intervention. In particular, infants with developmental and/or medical issues including middle ear disorders are at particular risk for longer time to confirmation of hearing loss.

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.

Congenital hearing loss

Congenital hearing loss (hearing loss that is present at birth) is one of the most prevalent chronic conditions in children. In the majority of developed countries, neonatal hearing screening programmes enable early detection; early intervention will prevent delays in speech and language development and has long-lasting beneficial effects on social and emotional development and quality of life. A diagnosis of hearing loss is usually followed by a search for an underlying aetiology. Congenital hearing loss might be attributed to environmental and prenatal factors, which prevail in low-income settings; congenital infections, particularly cytomegalovirus infection, are also a common risk factor for hearing loss. Genetic causes probably account for the majority of cases in developed countries; mutations can affect any component of the hearing pathway, in particular, inner ear homeostasis (endolymph production and maintenance) and mechano-electrical transduction (the conversion of a mechanical stimulus into electrochemical activity). Once the underlying cause of hearing loss is established, it might direct therapeutic decision making and guide prevention and (genetic) counselling. Management options include specific antimicrobial therapies, surgical treatment of craniofacial abnormalities and implantable or non-implantable hearing devices. An improved understanding of the pathophysiology and molecular mechanisms that underlie hearing loss and increased awareness of recent advances in genetic testing will promote the development of new treatment and screening strategies.

Follow-up in newborn hearing screening - A systematic review

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and Management of Congenital Sensorineural Hearing Loss

Hearing loss is the most common sensory disorder in the USA. The diagnosis of congenital hearing loss starts with newborn hearing screening, which is best performed with auditory brainstem evoked responses in order to avoid the risk of missing auditory neuropathy spectrum disorder. A careful history and physical exam can occasionally help reveal the etiology for congenital hearing loss. Imaging studies, either CT temporal bones or MRI of the internal auditory canals without gadolinium, and genetic testing, in particular for connexin 26, connexin 30, and Pendred syndrome, are the most useful diagnostic tests. Management of congenital hearing loss involves early fitting of amplification. Early cochlear implantation, preferably before 2 years of age, should be strongly considered for children with bilateral severe hearing loss.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Pediatric Hearing Healthcare in Kentucky's Appalachian Primary Care Setting

Diagnosis and intervention for infant hearing loss is often delayed in areas of healthcare disparity, such as rural Appalachia. Primary care providers play a key role in timely hearing healthcare. The purpose of this study was to assess the practice patterns of rural primary care providers (PCPs) regarding newborn hearing screening (NHS) and experiences with rural early hearing diagnosis and intervention programs in an area of known hearing healthcare disparity. Cross sectional questionnaire study. Appalachian PCP's in Kentucky were surveyed regarding practice patterns and experiences regarding the diagnosis and treatment of congenital hearing loss. 93 Appalachian primary care practitioners responded and 85% reported that NHS is valuable for pediatric health. Family practitioners were less likely to receive infant NHS results than pediatricians (54.5 versus 95.2%, p < 0.01). A knowledge gap was identified in the goal ages for diagnosis and treatment of congenital hearing loss. Pediatrician providers were more likely to utilize diagnostic testing compared with family practice providers (p < 0.001). Very rural practices (Beale code 7-9) were less likely to perform hearing evaluations in their practices compared with rural practices (Beale code 4-6) (p < 0.001). Family practitioners reported less confidence than pediatricians in counseling and directing care of children who fail newborn hearing screening. 46% felt inadequately prepared or completely unprepared to manage children who fail the NHS. Rural primary care providers face challenges in receiving communication regarding infant hearing screening and may lack confidence in directing and providing rural hearing healthcare for children.

Amblyaudia: Review of Pathophysiology, Clinical Presentation, and Treatment of a New Diagnosis

OBJECTIVE

Similar to amblyopia in the visual system, "amblyaudia" is a term used to describe persistent hearing difficulty experienced by individuals with a history of asymmetric hearing loss (AHL) during a critical window of brain development. Few clinical reports have described this phenomenon and its consequent effects on central auditory processing. We aim to (1) define the concept of amblyaudia and (2) review contemporary research on its pathophysiology and emerging clinical relevance.

DATA SOURCES

PubMed, Embase, and Cochrane databases.

REVIEW METHODS

A systematic literature search was performed with combinations of search terms: "amblyaudia," "conductive hearing loss," "sensorineural hearing loss," "asymmetric," "pediatric," "auditory deprivation," and "auditory development." Relevant articles were considered for inclusion, including basic and clinical studies, case series, and major reviews.

CONCLUSIONS

During critical periods of infant brain development, imbalanced auditory input associated with AHL may lead to abnormalities in binaural processing. Patients with amblyaudia can demonstrate long-term deficits in auditory perception even with correction or resolution of AHL. The greatest impact is in sound localization and hearing in noisy environments, both of which rely on bilateral auditory cues. Diagnosis and quantification of amblyaudia remain controversial and poorly defined. Prevention of amblyaudia may be possible through early identification and timely management of reversible causes of AHL.

IMPLICATIONS FOR PRACTICE

Otolaryngologists, audiologists, and pediatricians should be aware of emerging data supporting amblyaudia as a diagnostic entity and be cognizant of the potential for lasting consequences of AHL. Prevention of long-term auditory deficits may be possible through rapid identification and correction.

An Introduction to the Outcomes of Children with Hearing Loss Study

The landscape of service provision for young children with hearing loss has shifted in recent years as a result of newborn hearing screening and the early provision of interventions, including hearing technologies. It is expected that early service provision will minimize or prevent linguistic delays that typically accompany untreated permanent childhood hearing loss. The post-newborn hearing screening era has seen a resurgence of interest in empirically examining the outcomes of children with hearing loss to determine if service innovations have resulted in expected improvements in children's functioning. The Outcomes of Children with Hearing Loss (OCHL) project was among these recent research efforts, and this introductory article provides background in the form of literature review and theoretical discussion to support the goals of the study. The Outcomes of Children with Hearing Loss project was designed to examine the language and auditory outcomes of infants and preschool-age children with permanent, bilateral, mild-to-severe hearing loss, and to identify factors that moderate the relationship between hearing loss and longitudinal outcomes. The authors propose that children who are hard of hearing experience limitations in access to linguistic input, which lead to a decrease in uptake of language exposure and an overall reduction in linguistic experience. The authors explore this hypothesis in relation to three primary factors that are proposed to influence children's access to linguistic input: aided audibility, duration and consistency of hearing aid use, and characteristics of caregiver input.

A Structural Equation Modeling Approach to Examining Factors Influencing Outcomes with Cochlear Implant in Mandarin-Speaking Children

OBJECTIVE

To examine the direct and indirect effects of demographical factors on speech perception and vocabulary outcomes of Mandarin-speaking children with cochlear implants (CIs).

METHODS

115 participants implanted before the age of 5 and who had used CI before 1 to 3 years were evaluated using a battery of speech perception and vocabulary tests. Structural equation modeling was used to test the hypotheses proposed.

RESULTS

Early implantation significantly contributed to speech perception outcomes while having undergone a hearing aid trial (HAT) before implantation, maternal educational level (MEL), and having undergone universal newborn hearing screening (UNHS) before implantation had indirect effects on speech perception outcomes via their effects on age at implantation. In addition, both age at implantation and MEL had direct and indirect effects on vocabulary skills, while UNHS and HAT had indirect effects on vocabulary outcomes via their effects on age at implantation.

CONCLUSION

A number of factors had indirect and direct effects on speech perception and vocabulary outcomes in Mandarin-speaking children with CIs and these factors were not necessarily identical to those reported among their English-speaking counterparts.

Timeliness of service delivery for children with later-identified mild-to-severe hearing loss

PURPOSE

In this study, the authors examined diagnostic and intervention services for children identified with hearing loss (HL) after the newborn period.

METHOD

The authors compared ages at service delivery and length of delays between service delivery steps for 57 later-identified children with HL and 193 children who referred for assessment from the newborn hearing screen (NHS). For only later-identified children, regression models were used to investigate relationships among predictor variables and dependent variables related to service delivery.

RESULTS

Children who referred from the NHS received follow-up services at younger ages than later-identified children. Later-identified children had significantly longer delays from HL confirmation to entry into early intervention, compared to children who referred from the NHS. For later-identified children, degree of HL predicted ages at follow-up clinical services. Children with more severe HL received services at younger ages compared to children with milder HL. Gender predicted the length of the delay from confirmation to entry into early intervention, with girls demonstrating shorter delays.

CONCLUSIONS

The current results lend support to the need for ongoing hearing monitoring programs after the neonatal period, particularly when children enter early intervention programs because of language/developmental delays.

Sensory development

Sensory development is complex, with both morphologic and neural components. Development of the senses begins in early fetal life, initially with structures and then in-utero stimulation initiates perception. After birth, environmental stimulants accelerate each sensory organ to nearly complete maturity several months after birth. Vision and hearing are the best studied senses and the most crucial for learning. This article focuses on the cranial senses of vision, hearing, smell, and taste. Sensory function, embryogenesis, external and genetic effects, and common malformations that may affect development are discussed, and the corresponding sensory organs are examined and evaluated.

Effects of policy changes to universal newborn hearing screening follow-up in a university clinic

PURPOSE

The purpose of this study was to evaluate the effects of policy changes on loss to follow-up rates and the ability to achieve the goals of the American Academy of Pediatrics Joint Committee on Infant Hearing Screening (2007) for diagnosis of hearing loss by 3 months, amplification within 1 month of diagnosis, and start of intervention by 6 months.

METHOD

From the files of 111 infants, data were extracted on the following: date of birth, birth hospital, hometown, parents' ages, ethnicity, nursery status, medical history, age at initial evaluation and diagnosis, results of evaluation(s), and age at hearing aid fitting and start of early intervention. Data were compared with previously published data from the clinic (Krishnan, 2009).

RESULTS

Policy changes led to a decrease in loss to follow-up and a younger age at diagnosis of hearing loss. Infants identified with hearing loss were fit with amplification at younger ages but not within 1 month of diagnosis of hearing loss. Policy changes had positive outcomes on loss to follow-up and age of diagnosis and amplification.

CONCLUSIONS

Challenges remain in meeting the goals of amplification within 1 month of diagnosis and documenting the start of early intervention. Improved communication between and education of all parties involved in the care of infants is needed.

Quantity of parental language in the home environments of hard-of-hearing 2-year-olds

Automated analyses of full-day recordings were used to determine whether young children who are hard-of-hearing (HH) received similar levels of exposure to adult words and conversational interactions as age-matched peers with normal-hearing (NH). Differences in adult input between children in this study and in a normative database were considered. Finally, factors were examined that may have contributed to individual differences in the input characteristics of families. Results indicated that the NH and HH groups were exposed to similar numbers of adult words and conversational turns. However, both the NH and HH groups were exposed to more adult words and engaged in more conversational turns than the NH children in the normative sample. Considering only the HH group, both quantity of adult words and conversational exchanges were correlated with children's auditory characteristics. Children's receptive language ability was correlated with conversational exchanges but not with adult word counts.

Predictors of hearing aid use time in children with mild-to-severe hearing loss

PURPOSE

This study investigated predictors of hearing aid (HA) use time for children with mild-to-severe hearing loss (HL). Barriers to consistent HA use and reliability of parent report measures were also examined.

METHOD

Participants included parents of 272 children with HL. Parents estimated the amount of time the child used HAs daily. Regression analysis examined the relationships among independent variables and HA use time. To determine parental accuracy of HA use time, datalogging from the HAs was compared to the parents' estimates.

RESULTS

Longer HA use related to older age, poorer hearing, and higher maternal education. Parental consistency ratings revealed similar findings--younger children and children with milder HL wore HAs less consistently than older children and children with more severe HL. Parents' estimates and datalogging were significantly correlated; however, results suggested that parents overestimate the amount of time their children wear their HAs.

CONCLUSION

Certain variables were significantly related to the amount of time children wore their HAs. Consistency rating scales provided insight into circumstances that were challenging for families. Use of both parent reports and datalogging may allow clinicians and researchers to obtain a general estimate of HA use time.

Early Hearing Detection and Intervention: Parent Experiences With the Diagnostic Hearing Assessment

Purpose

The aim of this study was to investigate parent experiences with the infant diagnostic hearing evaluation process.

Method

This study used a cross-sectional survey design. Surveys were distributed via parent support organizations in December 2009 to parents of children with hearing loss. A total of 416 completed surveys were received from 43 states.

Results

The median age of diagnosis of hearing loss has decreased over time from 11 months of age to 2 months. For babies born between 2006 and 2009, the most frequently reported challenge to obtaining a diagnostic hearing evaluation by 3 months of age was a delay in appointment availability (36%). Just >¼ (27%) of parents reported that they did not feel comfortable in knowing what they needed to do next after talking with the audiologist at the time their child was diagnosed with hearing loss.

Conclusion

Significant progress has been made over the past 2 decades in reducing the age of hearing loss identification. However, many parents in this study experienced challenges that resulted in delays that exceeded Joint Committee on Infant Hearing (2007) recommendations of diagnosis by 3 months of age. The parent-reported experiences provide valuable information about areas that need further investigation to improve the early hearing detection and intervention process for children with hearing loss.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Identifying quality improvement opportunities in a universal newborn hearing screening program

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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