Age of suspicion, identification, and intervention for infants and young children with hearing loss: a national study

Neonatal hearing screening - does failure in TEOAE screening matter when the AABR test is passed?

PURPOSE

Newborns who fail the transient evoked otoacoustic emissions (TEOAE) but pass the automatic auditory brainstem response (AABR) in universal newborn hearing screening (UNHS), frequently have no further diagnostic test or follow-up. The present study aimed to investigate whether hearing loss might be missed by ignoring neonatal TEOAE failure in the presence of normal AABR.

METHODS

A retrospective analysis was conducted in newborns presenting between 2017 and 2021 to a tertiary referral centre due to failure in the initial UNHS. The main focus was on infants who failed TEOAE tests, but passed AABR screening. The clinical characteristics and audiometric outcomes were analysed and compared with those of other neonates.

RESULTS

Among 1,095 referred newborns, 253 (23%) failed TEOAE despite passing AABR screening. Of the 253 affected infants, 154 returned for follow-up. At 1-year follow-up, 46 (28%) achieved normal audiometric results. 32 (21%) infants had permanent hearing loss (HL) confirmed by diagnostic ABR, 58 (38%) infants had HL solely due to middle ear effusion (MEE), and for 18 (12%) infants HL was suspected without further differentiation. The majority of permanent HL was mild (78% mild vs. 13% moderate vs. 9% profound). The rate of spontaneous MEE clearance was rather low (29%) leading to early surgical intervention in 36 children. The profile of the risk factors for hearing impairment was similar to that of newborns with failure in both, TEOAE and AABR; however, there was a stronger association between the presence of risk factors and the incidence of HL (relative risk 1.55 vs. 1.06; odds ratio 3.61 vs. 1.80).

CONCLUSION

In newborns, the discordance between a "refer" in TEOAE and a "pass" in AABR screening is associated with a substantial prevalence of hearing impairment at follow-up, especially in the presence of risk factors.

Early Identification of Hearing Loss and Language Development at 32 Months of Age

This study examines the relationship between the early identification of hearing loss and language outcomes for deaf/hard of hearing (D/HH) children, with bilateral or unilateral hearing loss and with or without additional disabilities. It was hypothesized that hearing loss identified by 3 months of age would be associated with better language outcomes. Using a prospective, longitudinal design, 86 families completed developmental instruments at two time points: at an average age of 14.8 months and an average age of 32.1 months. Multiple regression examined how hearing loss identified by 3 months of age contributed to later language outcomes while controlling for developmental level at the first time point. Hearing loss identified by 3 months of age was positively associated with better language outcomes for D/HH children at 32 months of age; however, D/HH children still exhibited language delays, compared to normative scores for same-aged hearing peers for reported measures. Language outcomes of children with unilateral hearing loss were not better than those of children with mild-to-moderate bilateral hearing loss. Children with additional disabilities and more severe bilateral hearing loss had lower language scores than those without.

Speech Discrimination in Infancy Predicts Language Outcomes at 30 Months for Both Children with Normal Hearing and Those with Hearing Differences

BACKGROUND

Speech discrimination assessments are used to validate amplification fittings of older children who are hard of hearing (CHH). Unfortunately, speech discrimination is not assessed clinically ≤24 months and in turn no studies have investigated the relationship between speech discrimination during infancy and later language development among CHH.

OBJECTIVE

To examine the relationship between an individual infant's speech discrimination measured at 9 months and their expressive/receptive spoken language at 30 months for children with normal hearing (CNH) and CHH.

METHODS

Behavioral speech discrimination was assessed at 9 months and language assessments were conducted at 16, 24, and 30 months using a parent questionnaire, and at 30 months using the Mullen Scales of Early Learning among 90 infants (49 CNH; 41 CHH).

RESULTS

Conditioned Head Turn (CHT) performance for /a-i/ significantly predicted expressive and receptive language at 30 months across both groups. Parental questionnaires were also predictive of later language ability. No significant differences in speech discrimination or language outcomes between CNH and CHH were found.

CONCLUSIONS

This is the first study to document a positive relationship between infant speech discrimination and later language abilities in both early-identified CHH and CNH.

Hearing aid benefits in children with mild bilateral hearing loss: AUDIO-INFANS study

OBJECTIVES

There is a lack of consensus regarding the definition, consequences, and management of mild bilateral hearing loss in children. The objective of this study is to analyze the benefit of hearing aids in children with mild bilateral hearing loss by evaluating their functional hearing.

METHODS

This retrospective study included 57 children with mild bilateral hearing loss between 20 dB HL and 40 dB HL. Pure tone and speech audiometry thresholds were assessed with and without hearing aids. Two groups were subsequently formed: group E with an effective use of hearing aids (>10 h/day), and group IE whose use of hearing aids was deemed ineffective (<10 h/day).

RESULTS

Without hearing aids, the initial median of hearing level was 35 dB HL and 36 dB HL in the right and left ears, respectively, compared to 23 dB HL and 25 dB HL with hearing aids. The Lafon test performed on 25 children at 55 dB HL and 65 dB HL showed results ranging from 0% to 100% without hearing aids and from 90% to 100% with hearing aids. Scores obtained with hearing aids were significantly higher than those without them at an average speech level. Median age at diagnosis and at prescription were found to significantly influence the daily use of hearing aids.

CONCLUSIONS

Our results show that in the case of mild bilateral hearing loss, hearing aids have positive effects on the functional hearing of children and help them to no longer be disadvantaged. This study highlights the need to provide regular support to these children to ensure their optimal care in the event of hearing-related problems. Coordination between the different professionals working with these children is also necessary for their follow-up and appropriate management.

Overview of Medical Evaluation of Unilateral and Bilateral Hearing Loss in Children

Early identification, treatment, and medical evaluation of childhood hearing loss are essential to promoting language and social development, regardless of their age of presentation. Evaluation of hearing loss in children should prioritize reversible and treatable causes. Multiple algorithms have been established to address the changing prevalence of genetic or infectious contributions to hearing loss and include recommendations on laboratory testing, imaging, and genetic testing. Despite these recommendations, significant practice variation remains on assessing the etiology of hearing loss in children.

The History of Pediatric and Adult Hearing Screening

OBJECTIVES/HYPOTHESIS

To document the history of hearing seeing in children and adults.

STUDY DESIGN

A literature search in all languages was carried out with the terms of hearing screening from the following sources: Pub Med, Science Direct, World Catalog, Index Medicus, Google scholar, Google Books, National Library of Medicine, Welcome historical library and The Library of Congress.

METHODS

The primary sources consisting of books, scientific reports, public documents, governmental reports, and other written material were analyzed to document the history of hearing screening.

RESULTS

The concept of screening for medical conditions that, when found, could influence some form of the outcome of the malady came about during the end of 19th century. The first applications of screening were to circumscribe populations, schoolchildren, military personnel, and railroad employees. During the first half of the 20th century, screening programs were extended to similar populations and were able to be expanded on the basis of the improved technology of hearing testing. The concept of universal screening was first applied to the inborn errors of metabolism of newborn infants and particularly the assessment of phenylketonuria in 1963 by Guthrie and Susi. A limited use of this technique has been the detection of genes resulting in hearing loss. The use of a form of hearing testing either observational or physiological as a screen for all newborns was first articulated by Larry Fisch in 1957 and by the end of the 20th century newborn infant screening for hearing loss became the standard almost every nation worldwide.

CONCLUSIONS

Hearing screening for newborn infants is utilized worldwide, schoolchildren less so and for adults many industrial workers and military service undergo hearing screening, but this is not a general practice for screening the elderly.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:S1-S25, 2021.

Perception of vocal emotional prosody in children with hearing impairment

PURPOSE

The study aimed at testing the effect of supra segmental training on vocal emotional prosody perception of children with hearing impairment. The objectives of the study were to compare the perception of vocal emotional prosody (happy, sad, and neutral) in children with hearing impairment with and without a short-term prosody training and to draw correlations between the vocal emotional prosody perception scores and the subject factors - chronological age, age of hearing aid fitting, duration of the intensive intervention (speech, language and auditory training without breaks more than 30 days) and language age in children with hearing impairment.

METHOD

Thirty children with hearing impairment in the age range of 4.1-9.2 years with a language age of 3-7 years participated in the study. The authors formulated 24 concrete Malayalam sentences and their picture representations and these were recorded under three emotional variations (happy, sad, and neutral). Using random sampling, the thirty participants were divided into the control group (CWHI) and the experimental (CWHIt) group. The study was carried out in two phases; phase 1 (training) attended by only the experimental group and phase 2 (testing) attended by both the groups.

RESULTS

There was a significant difference between CWHI and CWHIt in the happy, sad, and neutral vocal emotional prosody conditions. Chronological age, duration of speech-language-auditory training, and language age showed a positive correlation with the vocal emotional prosody perception scores; and no correlation was found between the age of fitting of hearing aids and the emotion perception scores.

CONCLUSION

The results of the study points out that with adequate prosody training, the children with hearing impairment using benefiting hearing aids could improve their vocal emotional prosody perception. Owing to the role of prosody perception in speech & language, social and cognitive development, the supra segmental training should be made an integral part of the assessment and management intervention strategies.

Medical Referral Patterns and Etiologies for Children With Mild-to-Severe Hearing Loss

OBJECTIVES

To (1) identify the etiologies and risk factors of the patient cohort and determine the degree to which they reflected the incidence for children with hearing loss and (2) quantify practice management patterns in three catchment areas of the United States with available centers of excellence in pediatric hearing loss.

DESIGN

Medical information for 307 children with bilateral, mild-to-severe hearing loss was examined retrospectively. Children were participants in the Outcomes of Children with Hearing Loss (OCHL) study, a 5-year longitudinal study that recruited subjects at three different sites. Children aged 6 months to 7 years at time of OCHL enrollment were participants in this study. Children with cochlear implants, children with severe or profound hearing loss, and children with significant cognitive or motor delays were excluded from the OCHL study and, by extension, from this analysis. Medical information was gathered using medical records and participant intake forms, the latter reflecting a caregiver's report. A comparison group included 134 children with normal hearing. A Chi-square test on two-way tables was used to assess for differences in referral patterns by site for the children who are hard of hearing (CHH). Linear regression was performed on gestational age and birth weight as continuous variables. Risk factors were assessed using t tests. The alpha value was set at p < 0.05.

RESULTS

Neonatal intensive care unit stay, mechanical ventilation, oxygen requirement, aminoglycoside exposure, and family history were correlated with hearing loss. For this study cohort, congenital cytomegalovirus, strep positivity, bacterial meningitis, extracorporeal membrane oxygenation, and loop diuretic exposure were not associated with hearing loss. Less than 50% of children underwent imaging, although 34.2% of those scanned had abnormalities identified. No single imaging modality was preferred. Differences in referral rates were apparent for neurology, radiology, genetics, and ophthalmology.

CONCLUSIONS

The OCHL cohort reflects known etiologies of CHH. Despite available guidelines, centers of excellence, and high-yield rates for imaging, the medical workup for children with hearing loss remains inconsistently implemented and widely variable. There remains limited awareness as to what constitutes appropriate medical assessment for CHH.

Screening of Newborn Hearing at a Tertiary Care Hospital in South India

Hearing loss can have a devastating impact on the cognitive development and psychological well-being of children and their families. Newborn hearing screening should be given special attention especially in a country like ours where the burden of this disability is heavy. Screening all newborns irrespective of risk factors helps in better detection, and hence further management can be initiated at appropriate time. To implement newborn hearing screening at Vanivilas hospital and to estimate the incidence of hearing loss among the high risk groups. To create awareness about the need for detecting childhood deafness among parents and general population. To develop a centre of excellence for evaluation, intervention and rehabilitation for hearing impaired in a tertiary care hospital. Prospective study. All neonates born in Vanivilas Hospital attached to Bangalore Medical College and Research Institute underwent hearing screening using four stage protocols with otoacoustic emission (OAE) tests and final confirmation with Brainstem evoked response audiometry (BERA) tests. May 2015-May 2017. Number of newborns screened were 26,487, and 19 (0.717/1000) newborns were detected to have hearing impairment. The incidence of hearing loss among high risk group was 0.188/1000, and among the non risk group was 0.528/1000. Newborn hearing screening must be made mandatory and multi-staged protocol based screening for hearing loss should be implemented. This will make newborn screening programme more efficient and also will help in initiating treatment at an early stage so that further damage can be prevented.

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.

Service Delivery to Children With Mild Hearing Loss: Current Practice Patterns and Parent Perceptions

PURPOSE

This study investigates clinical practice patterns and parent perception of intervention for children with mild hearing loss (HL).

METHOD

Ages at and delays between service delivery steps (first diagnostic evaluation, confirmation of HL, hearing aid [HA] fitting, entry into early intervention) were investigated for 113 children with mild HL. Comparisons were made to children with moderate-to-severe HL. Parents of children with mild HL reported reasons for delays and their perceptions of intervention and amplification for their children.

RESULTS

Seventy-four percent of children with mild HL were identified through the newborn hearing screen; 26% were identified later due to passing or not receiving a newborn hearing screen. Ninety-four percent of children with mild HL were fit with HAs, albeit at significantly later ages than children with moderate-to-severe HL. Most parents indicated that their children benefited from HA use, but some parents expressed ambivalence toward the amount of benefit.

CONCLUSIONS

Audiologists appear to be moving toward regularly providing amplification for children with mild HL. However, delays in HA fittings indicate that further educating professionals and parents about the benefits of early amplification and intervention is warranted to encourage timely fitting and consistent use of HAs.

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.

Parent perceptions of their child's communication and academic experiences with cochlear implants

OBJECTIVE

To explore parent perceptions of communication and academic experiences of cochlear implant (CI) recipients under the age of 18.

DESIGN

Cross-sectional survey design. Two surveys (K-12, birth-5) queried parent perceptions of the impact of CI on communication, listening in various environments and academic achievement. Surveys contained 16-23 multiple choice and/or Likert ratings, plus four open-ended questions to assess reasons for obtaining a CI, satisfaction with CI and suggestions for professionals.

STUDY SAMPLE

Surveys were sent to 156 parents of CI recipients; 81 surveys returned; response rate 52%.

RESULTS

According to parent report, 95% of K-12 children and 100% of preschool children used spoken language as their primary mode of communication; majority of K-12 children performed same as or better than peers across academic subjects; 99% of respondents were pleased with their decision to obtain a CI. The most important reasons reported for choosing CIs were for their child to use the same language as their families and to effectively communicate in hearing society. Satisfaction with CI was better in quiet than in noise. Respondents stressed the importance of audiologists having excellent skills in CI management and programming.

CONCLUSIONS

Respondents were positive about the benefits of obtaining CI for their child.

Speech Recognition and Parent Ratings From Auditory Development Questionnaires in Children Who Are Hard of Hearing

OBJECTIVES

Progress has been made in recent years in the provision of amplification and early intervention for children who are hard of hearing. However, children who use hearing aids (HAs) may have inconsistent access to their auditory environment due to limitations in speech audibility through their HAs or limited HA use. The effects of variability in children's auditory experience on parent-reported auditory skills questionnaires and on speech recognition in quiet and in noise were examined for a large group of children who were followed as part of the Outcomes of Children with Hearing Loss study.

DESIGN

Parent ratings on auditory development questionnaires and children's speech recognition were assessed for 306 children who are hard of hearing. Children ranged in age from 12 months to 9 years. Three questionnaires involving parent ratings of auditory skill development and behavior were used, including the LittlEARS Auditory Questionnaire, Parents Evaluation of Oral/Aural Performance in Children rating scale, and an adaptation of the Speech, Spatial, and Qualities of Hearing scale. Speech recognition in quiet was assessed using the Open- and Closed-Set Test, Early Speech Perception test, Lexical Neighborhood Test, and Phonetically Balanced Kindergarten word lists. Speech recognition in noise was assessed using the Computer-Assisted Speech Perception Assessment. Children who are hard of hearing were compared with peers with normal hearing matched for age, maternal educational level, and nonverbal intelligence. The effects of aided audibility, HA use, and language ability on parent responses to auditory development questionnaires and on children's speech recognition were also examined.

RESULTS

Children who are hard of hearing had poorer performance than peers with normal hearing on parent ratings of auditory skills and had poorer speech recognition. Significant individual variability among children who are hard of hearing was observed. Children with greater aided audibility through their HAs, more hours of HA use, and better language abilities generally had higher parent ratings of auditory skills and better speech-recognition abilities in quiet and in noise than peers with less audibility, more limited HA use, or poorer language abilities. In addition to the auditory and language factors that were predictive for speech recognition in quiet, phonological working memory was also a positive predictor for word recognition abilities in noise.

CONCLUSIONS

Children who are hard of hearing continue to experience delays in auditory skill development and speech-recognition abilities compared with peers with normal hearing. However, significant improvements in these domains have occurred in comparison to similar data reported before the adoption of universal newborn hearing screening and early intervention programs for children who are hard of hearing. Increasing the audibility of speech has a direct positive effect on auditory skill development and speech-recognition abilities and also may enhance these skills by improving language abilities in children who are hard of hearing. Greater number of hours of HA use also had a significant positive impact on parent ratings of auditory skills and children's speech recognition.

Economic evaluation of long-term impacts of universal newborn hearing screening

OBJECTIVE

Little is known about the long-term efficacious and economic impacts of universal newborn hearing screening (UNHS).

DESIGN

An analytical Markov decision model was framed with two screening strategies: UNHS with transient evoked otoacoustic emission (TEOAE) test and automatic acoustic brainstem response (aABR) test against no screening. By estimating intervention and long-term costs on treatment and productivity losses and the utility of life years determined by the status of hearing loss, we computed base-case estimates of the incremental cost-utility ratios (ICURs). The scattered plot of ICUR and acceptability curve was used to assess the economic results of aABR versus TEOAE or both versus no screening.

STUDY SAMPLE

A hypothetical cohort of 200,000 Taiwanese newborns.

RESULTS

TEOAE and aABR dominated over no screening strategy (ICUR = $-4800.89 and $-4111.23, indicating less cost and more utility). Given $20,000 of willingness to pay (WTP), the probability of being cost-effective of aABR against TEOAE was up to 90%.

CONCLUSIONS

UNHS for hearing loss with aABR is the most economic option and supported by economically evidence-based evaluation from societal perspective.

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.

Clinical Practice Guideline: Otitis Media with Effusion (Update)

OBJECTIVE

This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should 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 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

Vocabulary Knowledge of Children With Cochlear Implants: A Meta-Analysis

This article employs meta-analysis procedures to evaluate whether children with cochlear implants demonstrate lower spoken-language vocabulary knowledge than peers with normal hearing. Of the 754 articles screened and 52 articles coded, 12 articles met predetermined inclusion criteria (with an additional 5 included for one analysis). Effect sizes were calculated for relevant studies and forest plots were used to compare differences between groups of children with normal hearing and children with cochlear implants. Weighted effect size averages for expressive vocabulary measures (g = -11.99; p < .001) and for receptive vocabulary measures (g = -20.33; p < .001) indicated that children with cochlear implants demonstrate lower vocabulary knowledge than children with normal hearing. Additional analyses confirmed the value of comparing vocabulary knowledge of children with hearing loss to a tightly matched (e.g., socioeconomic status-matched) sample. Age of implantation, duration of implantation, and chronological age at testing were not significantly related to magnitude of weighted effect size. Findings from this analysis represent a first step toward resolving discrepancies in the vocabulary knowledge literature.

Factors Affecting Early Services for Children Who Are Hard of Hearing

PURPOSE

To describe factors affecting early intervention (EI) for children who are hard of hearing, we analyzed (a) service setting(s) and the relationship of setting to families' frequency of participation, and (b) provider preparation, caseload composition, and experience in relation to comfort with skills that support spoken language for children who are deaf and hard of hearing (CDHH).

METHOD

Participants included 122 EI professionals who completed an online questionnaire annually and 131 parents who participated in annual telephone interviews.

RESULTS

Most families received EI in the home. Family participation in this setting was significantly higher than in services provided elsewhere. EI professionals were primarily teachers of CDHH or speech-language pathologists. Caseload composition was correlated moderately to strongly with most provider comfort levels. Level of preparation to support spoken language weakly to moderately correlated with provider comfort with 18 specific skills.

CONCLUSIONS

Results suggest family involvement is highest when EI is home-based, which supports the need for EI in the home whenever possible. Access to hands-on experience with this population, reflected in a high percentage of CDHH on providers' current caseloads, contributed to professional comfort. Specialized preparation made a modest contribution to comfort level.

The Influence of Hearing Aid Use on Outcomes of Children With Mild Hearing Loss

PURPOSE

This study examined the effects of consistent hearing aid (HA) use on outcomes in children with mild hearing loss (HL).

METHOD

Five- or 7-year-old children with mild HL were separated into 3 groups on the basis of patterns of daily HA use. Using analyses of variance, we compared outcomes between groups on speech and language tests and a speech perception in noise task. Regression models were used to investigate the influence of cumulative auditory experience (audibility, early intervention, HA use) on outcomes.

RESULTS

Full-time HA users demonstrated significantly higher scores on vocabulary and grammar measures compared with nonusers. There were no significant differences between the 3 groups on articulation or speech perception measures. After controlling for the variance in age at confirmation of HL, level of audibility, and enrollment in early intervention, only amount of daily HA use was a significant predictor of grammar and vocabulary.

CONCLUSIONS

The current results provide evidence that children's language development benefits from consistent HA use. Nonusers are at risk in areas such as vocabulary and grammar compared with other children with mild HL who wear HAs regularly. Service providers should work collaboratively to encourage consistent HA use.

A triagem auditiva neonatal antecipa o diagnóstico e a intervenção em crianças com perda auditiva?

Objetivo Identificar a idade de diagnóstico, intervenção e amplificação pré e pós-implantação da Triagem Auditiva Neonatal (TAN) em um serviço de saúde auditiva e comparar aos indicadores propostos pelo Comitê Conjunto para Audição Infantil.Métodos Trezentos e treze prontuários de crianças atendidas no setor de reabilitação auditiva foram analisados, verificando se foi realizada a triagem auditiva e seu resultado, suspeita e idade de diagnóstico, intervenção e amplificação e se estas últimas atendiam aos indicadores preconizados: três meses para diagnóstico e seis meses para intervenção.Resultados Crianças identificadas pela TAN foram diagnosticadas e iniciaram a intervenção mais cedo do que as que não realizaram. Considerando-se a demanda institucional pré e pós a implantação da TAN, observou-se redução da idade de intervenção e amplificação após a implantação. Independentemente do resultado obtido na TAN (passa/falha), as crianças que passaram pela triagem apresentaram vantagem, quando comparadas às não triadas, uma vez que, dentre as triadas, antecipou-se o diagnóstico, a intervenção e a amplificação. Menos da metade das crianças que falharam na TAN concluíram o diagnóstico e iniciaram a intervenção no tempo preconizado.Conclusão A TAN antecipou o diagnóstico e a intervenção em crianças com perda auditiva. Contudo, fatores como a não adesão da família e as peculiaridades do diagnóstico retardaram os processos, impedindo que os indicadores preconizados fossem alcançados, na maior parte das crianças.

Evaluating reporting and process quality of publications on UNHS: a systematic review of programmes

Background

Congenital hearing loss is one of the most frequent birth defects, and Early Detection and Intervention has been found to improve language outcomes. The American Academy of Pediatrics (AAP) and the Joint Committee on Infant Hearing (JCIH) established quality of care process indicators and benchmarks for Universal Newborn Hearing Screening (UNHS). We have aggregated some of these indicators/benchmarks according to the three pillars of universality, timely detection and overreferral. When dealing with inter-comparison, relying on complete and standardised literature data becomes crucial.

The purpose of this paper is to verify whether literature data on UNHS programmes have included sufficient information to allow inter-programme comparisons according to the indicators considered.

Methods

We performed a systematic search identifying UNHS studies and assessing the quality of programmes.

Results

The identified 12 studies demonstrated heterogeneity in criteria for referring to further examinations during the screening phase and in identifying high-risk neonates, protocols, tests, staff, and testing environments. Our systematic review also highlighted substantial variability in reported performance data. In order to optimise the reporting of screening protocols and process performance, we propose a checklist. Another result is the difficulty in guaranteeing full respect for the criteria of universality, timely detection and overreferral.

Conclusions

Standardisation in reporting UNHS experiences may also have a positive impact on inter-program comparisons, hence favouring the emergence of recognised best practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0404-x) contains supplementary material, which is available to authorized users.

Air and Bone Conduction Click and Tone-Burst Auditory Brainstem Thresholds Using Kalman Adaptive Processing in Nonsedated Normal-Hearing Infants

OBJECTIVES

To study normative thresholds and latencies for click and tone-burst auditory brainstem response (TB-ABR) for air and bone conduction in normal infants and those discharged from neonatal intensive care units, who passed newborn hearing screening and follow-up distortion product otoacoustic emission. An evoked potential system (Vivosonic Integrity) that incorporates Bluetooth electrical isolation and Kalman-weighted adaptive processing to improve signal to noise ratios was employed for this study. Results were compared with other published data.

DESIGN

One hundred forty-five infants who passed two-stage hearing screening with transient-evoked otoacoustic emission or automated auditory brainstem response were assessed with clicks at 70 dB nHL and threshold TB-ABR. Tone bursts at frequencies between 500 and 4000 Hz were used for air and bone conduction auditory brainstem response testing using a specified staircase threshold search to establish threshold levels and wave V peak latencies.

RESULTS

Median air conduction hearing thresholds using TB-ABR ranged from 0 to 20 dB nHL, depending on stimulus frequency. Median bone conduction thresholds were 10 dB nHL across all frequencies, and median air-bone gaps were 0 dB across all frequencies. There was no significant threshold difference between left and right ears and no significant relationship between thresholds and hearing loss risk factors, ethnicity, or gender. Older age was related to decreased latency for air conduction. Compared with previous studies, mean air conduction thresholds were found at slightly lower (better) levels, while bone conduction levels were better at 2000 Hz and higher at 500 Hz. Latency values were longer at 500 Hz than previous studies using other instrumentation. Sleep state did not affect air or bone conduction thresholds.

CONCLUSIONS

This study demonstrated slightly better wave V thresholds for air conduction than previous infant studies. The differences found in the present study, while statistically significant, were within the test step size of 10 dB. This suggests that threshold responses obtained using the Kalman weighting software were within the range of other published studies using traditional signal averaging, given step-size limitations. Thresholds were not adversely affected by variable sleep states.

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.

Performance and characteristics of the Newborn Hearing Screening Programme in England: The first seven years

Objective: To assess the performance of the universal newborn hearing screen in England. Design: Retrospective analysis of population screening records. Study sample: A total of 4 645 823 children born 1 April 2004 to 31 March 2013. Results: 97.5% of the eligible population complete screening by 4/5 weeks of age and 98.9% complete screening by three months of age. The refer rate for the 12/13 birth cohort is 2.6%. The percentage of screen positive (i.e. referred) babies commencing follow up by four weeks of age and six months of age is 82.5% and 95.8% respectively. The yield of bilateral PCHL from the screen is around 1/1000. For bilateral PCHL in the 12/13 birth cohort the median age is nine days at screen completion, 30 days at entry into follow up, 49 days at confirmation, 50 days at referral to early intervention, and 82 days at hearing-aid fitting. Conclusion: The performance of the newborn hearing screening programme has improved continuously. The yield of bilateral PCHL from the screen is about 1/1000 as expected. The age of identification and management is well within the first six months of life, although there remains scope for further improvement with respect to timely entry into follow up.

Developmental outcomes of early-identified children who are hard of hearing at 12 to 18 months of age

AIMS

To examine the developmental outcomes of early-identified children who are hard of hearing, at 12 to 18 months of age, compared to those for children of similar age with normal hearing; and to investigate parent and child factors that are associated with these developmental outcomes.

METHODS

As part of a prospective study, 28 children with mild to severe hearing loss between the ages of 12 and 18 months and 42 children with normal hearing of similar age completed a comprehensive assessment battery. All children with hearing loss were identified by newborn hearing screening and amplified, on average, by 5 months of age. Outcome measures included: Mullen Scales of Early Learning; Preschool Language Scale-4th Ed; MacArthur-Bates Communicative Development Inventory; Infant-Toddler Social and Emotional Assessment; Vineland Adaptive Behavior Scales, Second Edition; Parenting Stress Index-Short Form; and Maternal Self-Efficacy Scale.

RESULTS

Children with hearing loss scored comparably to children with normal hearing on select outcome measures, with mean scores for both groups falling within normal limits. Greater maternal self-efficacy was associated with children's better language skills, adaptive behavior, social-emotional competence, and fewer problem behaviors.

CONCLUSION

Very young children with mild to severe hearing loss, who are identified early and provided prompt intervention that includes amplification, can demonstrate age appropriate development in multiple domains. Results also underscore the significance of parenting factors, especially perceived maternal self-efficacy, in relation to positive developmental outcomes for these children early in life.

Universal newborn screening for congenital CMV infection: what is the evidence of potential benefit?

Congenital CMV infection is a leading cause of childhood disability. Many children born with congenital CMV infection are asymptomatic or have nonspecific symptoms and therefore are typically not diagnosed. A strategy of newborn CMV screening could allow for early detection and intervention to improve clinical outcomes. Interventions might include antiviral drugs or nonpharmaceutical therapies such as speech-language therapy or cochlear implants. Using published data from developed countries, we analyzed existing evidence of potential benefit that could result from newborn CMV screening. We first estimated the numbers of children with the most important CMV-related disabilities (i.e. hearing loss, cognitive deficit, and vision impairment), including the age at which the disabilities occur. Then, for each of the disabilities, we examined the existing evidence for the effectiveness of various interventions. We concluded that there is good evidence of potential benefit from nonpharmaceutical interventions for children with delayed hearing loss that occurs by 9 months of age. Similarly, we concluded that there is fair evidence of potential benefit from antiviral therapy for children with hearing loss at birth and from nonpharmaceutical interventions for children with delayed hearing loss occurring between 9 and 24 months of age and for children with CMV-related cognitive deficits. We found poor evidence of potential benefit for children with delayed hearing loss occurring after 24 months of age and for children with vision impairment. Overall, we estimated that in the United States, several thousand children with congenital CMV could benefit each year from newborn CMV screening, early detection, and interventions.

Listening and Learning: Using Telepractice to Serve Children and Adults with Hearing Loss

Families of children with hearing loss and adults who also have been diagnosed with hearing loss require audiologic management, effective hearing technology, and consistent intervention or rehabilitation to improve their communication. Parents of young children with hearing loss who have chosen a listening and spoken language approach, such as Auditory-Verbal Therapy (AVT), may struggle to find qualified providers who can deliver these services. Similarly, adults with hearing loss also may find it challenging to enroll in aural rehabilitation services due to a lack of availability. The Telepractice and eLearning Laboratory (TeLL) in the School of Speech-Language Pathology and Audiology at the University of Akron has developed a model of telepractice service delivery to provide AVT to families of young children with hearing loss and adult aural rehabilitation services. This paper describes the rationale for establishing these services and a general framework that guides service delivery.

Cost-effectiveness analysis of a national neonatal hearing screening program in China: conditions for the scale-up

BACKGROUND

In 2009, the Chinese Ministry of Health recommended scale-up of routine neonatal hearing screening - previously performed primarily only in select urban hospitals - throughout the entire country.

METHODS

A decision analytical model for a simulated population of all live births in china was developed to compare the costs and health effects of five mutually exclusive interventions: 1) universal screening using Otoacoustic Emission (OAE) and Automated Auditory Brainstem Response (AABR); 2) universal OAE; 3) targeted OAE and AABR; 4) targeted OAE; and 5) no screening. Disability-Adjusted Life Years (DALYs) were calculated for health effects.

RESULTS AND DISCUSSION

Based on the cost-effectiveness and potential health outcomes, the optimal path for scale-up would be to start with targeted OAE and then expand to universal OAE and universal OAE plus AABR. Accessibility of screening, diagnosis, and intervention services significantly affect decision of the options.

CONCLUSION

In conclusion, to achieve cost-effectiveness and best health outcomes of the NHS program, the accessibility of screening, diagnosis, and intervention services should be expanded to reach a larger population. The results are thus expected to be of particular benefit in terms of the 'rolling out' of the national plan.

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.

Age of identification of hearing impairment in Mumbai--a trend analysis

Implementation of Universal Newborn Hearing Screening (UNHS) has led to lowering the age of identification of congenital hearing loss in children. In the absence of UNHS in Mumbai (India), it is pertinent to establish a data base on the age of identification of permanent hearing loss in children to facilitate affirmative action.

OBJECTIVE

To study the trend in age of identification (AOI) of hearing impairment in children studying in special schools.

METHODS

This retrospective study was a survey conducted on a convenient sample. The authentic data about date of birth and age of identification (AOI) of 510 children were collected through parental interview, and scrutiny of documents like birth certificates, first audiological report maintained in special schools/institutes/hospitals.

RESULTS

Time series analysis of the data concluded that from 1989 to 2008, AOI has reduced by 9.59 months. AOI has not reached one year even by 2008 and is much below the target of three months of age as per the recommendation of Joint Committee on Infant Hearing (2007).

CONCLUSION

In absence of Universal Newborn Hearing Screening (UNHS) in Mumbai (India) the present efforts do not seem to be enough in lowering the age of identification of hearing loss and policy decision is warranted.

Impact of co-occurring birth defects on the timing of newborn hearing screening and diagnosis

PURPOSE

Early detection of hearing loss in all newborns and timely intervention are critical to children's cognitive, verbal, behavioral, and social development. The initiation of appropriate early intervention services before 6 months of age can prevent or reduce negative developmental consequences. The purpose of this study was to assess, using large, population-based registries, the effect of co-occurring birth defects (CBDs) on the timing and overall rate of hearing screening and diagnosis.

METHOD

The authors linked statewide data from newborn hearing screenings, a birth defects registry, and birth certificates to assess the timeliness of newborn hearing screening and diagnosis of hearing loss (HL) for infants with and without CBDs in 485 children with confirmed HL.

RESULTS

Nearly one third (31.5%) of children with HL had 1 or more CBDs. The presence of CBDs prolonged the time of the initial infant hearing screening, which contributed to further delays in the subsequent diagnosis of HL.

CONCLUSIONS

Better coordination of HL assessment into treatment plans for children with CBDs may enable earlier diagnosis of HL and provide opportunities for intervention that will affect long-term developmental outcomes for these children.

Outcome of a newborn hearing screening program in a tertiary hospital in Malaysia: the first five years

BACKGROUND AND OBJECTIVE

Universal newborn hearing screening (UNHS) was started in the Hospital Universiti Sains Malaysia (HUSM) in January 2003. To comply with international standards, we determined the outcome of the newborn hearing screening program for the first 5 years of its implementation, from January 2003 to December 2007.

METHODS

The program screened all infants who were delivered in HUSM. In a retrospective review, the outcomes in terms of coverage, prevalence of hearing impairment, referral rate for each screening, age at detection of hearing impairment and at hearing aid-fitting were analyzed.

RESULTS

Ninety-eight percent of newborns were screened. The study included 16,100 randomly selected newborns. The initial screening referral rate was 25.5%. The prevalence of default for second and third screening was 33.9% and 40.7%, respectively. The mean (SD) age at detection of hearing impairment was 3.3 months (0.86). The mean (SD) age at fitting of a hearing aid was 13.6 (4.8) months.The prevalence of hearing impairment was 0.09%.

CONCLUSION

A newborn hearing screening program is an important tool for early diagnosis and treatment. Even though the prevalence of hearing impairment may be low, the problem needs to be addressed early as the development of infants requires normal hearing.

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

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

Classification of childhood hearing impairment: implications for rehabilitation in developing countries

AIM

To ascertain the rehabilitation needs of hearing impaired school entrants in developing countries based on current criteria for evaluating classification of childhood hearing impairment.

METHODS

The profile of hearing impairment was examined in 50 children from eight randomly selected mainstream schools, based on findings from medical history, physical examination, otoscopy, pure-tone audiometry and tympanometry. The hearing thresholds across frequencies 0.25 - 8.0 kHz were analysed. The results were compared with conventional pure-tone averages (0.5 - 4.0 kHz) and WHO's criteria/threshold for disabling hearing impairment.

RESULTS

Seventeen (94.4%) of the 18 children with conductive hearing loss based on conventional audiometry had high-frequency hearing loss. Similarly, 10 children (83.3%) of the 12 children with sensorineural hearing loss and 19 children (95%) of the 20 children with mixed hearing loss had high-frequency hearing loss. Forty-six hearing impaired children (92%): comprising those with permanent unilateral hearing loss > 30 dBHL, permanent hearing loss would have been missed by WHO criteria.

CONCLUSIONS

Conventional school audiometry and WHO criteria for disabling hearing impairment are unlikely to detect the full spectrum of hearing disability in relation to activity limitation and participation restriction. The rehabilitation needs of the affected children cannot therefore be appropriately addressed by these approaches.

Infant hearing loss in South Africa: age of intervention and parental needs for support

Hearing loss is referred to as the silent, overlooked epidemic in developing countries, and data reporting the mean age of diagnosis and intervention is virtually non-existent due to limited systematic or routine screening programs. The objective of this paper is to present findings of recent practice in early diagnosis and intervention services in an urban South African context, with specific reference to parental needs for support. Data was collected by means of questionnaire surveys for 54 parents of children with congenital or early-onset hearing loss, followed by focus group discussions conducted with 10 parents. The results of this study indicate the mean age of diagnosis to be 23 months (+/-18 SD), the mean age of initial hearing-aid fitting to be 28 months (+/-19 SD), and the mean age of enrollment into an early intervention program to be 31 months (+/-19 SD). In addition, results signify that this diverse and challenging population of parents of young hearing-impaired children largely depends on the ongoing support, guidance, and commitment of the pediatric audiologist.

Gut hyperpermiability after ischemia and reperfusion: attenuation with adrenomedullin and its binding protein treatment

Ischemia bowel remains a critical problem resulting in up to 80% mortality. The loss of gut barrier function plays an important role. Our previous studies have shown that administration of adrenomedullin (AM), a novel vasoactive peptide, and its binding protein (AMBP-1), reduces the systemic inflammatory response and organ injury after systemic ischemia induced by hemorrhagic shock. However, it remains unknown whether administration of AM/AMBP-1 preserves gut barrier function after gut ischemia reperfusion (I/R). We therefore hypothesized that AM/AMBP-1 prevents structural and functional damages to the intestinal mucosa after gut I/R. To test this, gut ischemia was induced by placing a microvascular clip across the superior mesenteric artery (SMA) for 90 min in male adult rats. After release of the SMA clamp, AM (12 mug/kg BW) and AMBP-1 (40 mug/kg BW) in combination or vehicle (1-ml normal saline) were administered intravenously over a period of 30 min. The mucosal barrier function in the small intestine was assessed in an isolated everted ileum sac using fluorescein-isothiocyanate dextran (FD4) at 4 h after AM/AMBP-1 treatment. FD4 clearance was used as a measure of gut permeability. In additional groups of animals, blood and small intestine samples were collected at 4 h after the treatment. Morphological changes in the small intestine were assessed by H-E staining. Serum concentrations of alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, lactate and lactate dehydrogenase were also assessed. The gene expression and protein levels of TNF-alpha in the small intestine were determined by RT-PCR and ELISA, respectively. Our results showed that administration of AM/AMBP-1 significantly attenuated the development of intestinal mucosal hyperpermeability during the reperfusion. Treatment with AM/AMBP-1 dramatically improved I/R-induced intestinal mucosal damages, attenuated remote organ injury, and downregulated gene expression and protein levels of TNF-alpha in the small intestine. In conclusion, AM/AMBP-1 attenuates structural and functional damages to the intestinal mucosa, and it appears to be a novel treatment for reperfusion injury after gut ischemia. The beneficial effect of AM/AMBP-1 on gut barrier function after I/R is associated with downregulation of TNF-alpha.

Vocalizations of infants with hearing loss compared with infants with normal hearing: Part I--phonetic development

OBJECTIVE

Infants with hearing loss are known to be slower to develop spoken vocabulary than peers with normal hearing. Previous research demonstrates that they differ from normal-hearing children in several aspects of prelinguistic vocal development. Less is known about the vocalizations of early-identified infants with access to current hearing technologies. This longitudinal study documents changes in prelinguistic vocalizations in early-identified infants with varying degrees of hearing loss, compared with a group of infants with normal hearing. It was hypothesized that infants with hearing loss would demonstrate phonetic delays and that selected aspects of phonetic learning may be differentially affected by restricted auditory access.

DESIGN

The vocalizations and early verbalizations of 21 infants with normal hearing and 12 early-identified infants with hearing loss were compared over a period of 14 mo (from 10 to 24 mo of age). Thirty-minute mother-child interaction sessions were video recorded at 6- to 8-wk intervals in a laboratory playroom setting. Syllable complexity changes and consonantal development were quantified from vocalizations and early verbalizations. Early behaviors were related to speech production measures at 36 mo of age. Participants with hearing loss were recruited from local audiology clinics and early intervention programs. Participants with normal hearing were recruited through day care centers and pediatrician offices.

RESULTS

Relative to age-matched, normal-hearing peers, children with hearing loss were delayed in the onset of consistent canonical babble. However, certain children with moderately-severe losses babbled on time, and infants with cochlear implants babbled within 2 to 6 mo of implantation. The infants with hearing loss had smaller consonantal inventories and were slower to increase syllable shape complexity than age-matched normal-hearing peers. The overall pattern of results suggested that consonant development in infants with hearing loss was delayed but not qualitatively different from children with normal hearing. Delays appeared to be less pronounced than suggested by previous research. However, fricative/affricate development progressed slowly in infants with hearing loss and divergence from the patterns of normal-hearing children was observed. Six children (2 with normal hearing; 4 with hearing loss) were identified as atypical, based on their rates of development. At 24 mo of age, these children persisted in producing a high proportion (0.59) of vocalizations lacking consonants, which was negatively correlated with Goldman-Fristoe scores at 36 mo (r = -0.60).

CONCLUSIONS

Results suggest that early-identified children are delayed in consonant and syllable structure development, which may influence early word learning rates. Fricative/affricate development appears to be challenging for some infants with hearing loss. This may be related to the effects of sensorineural hearing loss on high-frequency information, restricted bandwidth provided by amplification, and reduced audibility in contexts of noise and reverberation. Delayed fricative use may have implications for morphological development. Atypically slow rates of change in syllable development may indicate that a child is at risk for delayed speech development.

Universal neonatal hearing screening: the Siena (Italy) experience on 19,700 newborns

BACKGROUND

Hearing loss (HL) is likely to be the most common congenital abnormality in humans, with a reported prevalence of 1 to 3 per 1000 live births. Early detection and intervention is critical to prevent the adverse consequences of a delayed diagnosis on speech, language and cognitive development. As 33-50% of all congenital HLs cannot be detected in a selective hearing risk, use of universal neonatal hearing screening (UNHS) programs is expanding.

AIMS

We tested the value of a UNHS protocol, based on a two-stage strategy of Transient Evoked Otoacoustic Emissions (TEOAEs) in all infants, followed by diagnostic auditory brainstem response (ABR) testing in those infants who did not meet TEOAE pass criteria and those infants at high risk for hearing loss.

METHODS

TEOAES (292 DP Echoport OAE Analyzer) served as the initial screen, followed by diagnostic ABR (Amplaid MK12) in newborns that did not meet pass criteria for TEOAEs. Additionally, all infants at high audiologic risk according to the Joint Committee on Infant Hearing received a diagnostic ABR evaluation. Of 21,125 total live births, 19,700 were tested (April 1, 1998-July 31, 2006). Accuracy of the UNHS strategy in predicting congenital HL was evaluated by calculating sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

Prevalence for all HLs in the neonatal period was 1.78/1000 l.b. (35/19,700), with bilateral HL in 1.42/1000 l.b. (28/19,700) [low risk rate: 0.43/1000 l.b. (8/18,356); high risk infants rate: 14.88/1000 l.b. (20/1344)]. All the HL infants were diagnosed <3 and received intervention <6 months age. ROC curves results showed 100% sensitivity (95% C.I.: 89.0-100) and 99.3% specificity (95% C.I.: 99.2-99.4) of the two-stage strategy in detecting congenital HLs [area under the ROC curve: 0.997 (95% C.I.: 0.995-0.997)].

CONCLUSIONS

(1) The epidemiology of congenital HLs widely justifies UNHS; (2) a two-stage TEOAE and diagnostic ABR screening for congenital HL is feasible, minimally invasive and accurate in the early detection of congenital HL; and (3) a congenital HL screening strategy based exclusively on the use of TEOAEs should always consider the possibility of false negative cases.

The prevalence of congenital and early-onset hearing loss in Jordanian and Israeli infants

The objective of the study was to investigate the prevalence of congenital and early-onset hearing loss, and the influence of the known risk factors for hearing loss on infants in Jordan and Israel. Subjects were a total of nearly 17,000 infants from both countries, including infants with and without risk factors for hearing loss. The hearing screening protocol included distortion product otoacoustic emission, followed in case of repeated OAE referral or high risk (HR) infant by diagnostic auditory brainstem responses. The results indicate that the prevalence and severity of hearing loss amongst Jordanian infants (1.37%) is remarkably higher as compared to the Israeli infants (0.48%). The overall prevalence of bilateral SNHL was seven times more in the Jordanian infants, 18 times in non-risk, and three times in the HR infants relative to the Israeli infants. Risk factors including family history, hyperbilirubinemia, bacterial meningitis, and associated syndromes were more prevalent amongst Jordanian infants. This unique study underscores the importance of sharing and exchanging information to create empirical data to guide health-care providers in adapting protocols to the local constraints in developing countries.

The ages of suspicion, diagnosis, amplification, and intervention in deaf children

OBJECTIVES

The present study sought to determine the average ages of suspicion, diagnosis, and amplification of profound hearing loss and intervention in deaf children and to compare at-risk and not-at-risk children based on the studied ages.

METHODS

This study was conducted on 86 children under 6 years of age with profound bilateral hearing loss in Newsha Aural Rehabilitation Center in Tehran from July to December 2005. Data were gathered through the completion of a questionnaire by the children's parents, and the children's medical and rehabilitative records were utilized in order to determine the kind and degree of hearing loss.

RESULTS

The mean ages of suspicion, diagnosis, amplification, and intervention were 12.6+/-8.9, 15.2+/-9.3, 20.5+/-11.1, and 22.3+/-11.6 months, respectively; there being statistically significant differences between them. 47.7% of the children were in the high-risk group, and statistically there were no significant differences between the at-risk and not-at-risk children in the studied ages. Of all the neonatal diseases investigated, hyperbilirubinemia was the most frequent (40.7%), and there were also four cases of meningitis and six cases of measles. In terms of consanguinity, mating of first cousins was 41.9% and mating of second cousins and farther familial relationships was 14%. After suspecting hearing loss in their children, the parents had visited physicians (57%), audiologists (37.2%), speech therapists (2.3%), or other specialists (3.5%) for the first time. The economic circumstances of the families had a significant bearing on the average ages of suspicion, diagnosis, amplification, and intervention.

CONCLUSIONS

Despite the remarkable improvement in the average ages of suspicion, diagnosis, amplification, and intervention in comparison with those reported in a previous study carried out in Iran (2002), there is still noticeable difference between these ages and those suggested by the Joint Committee on Infant Hearing.

Hearing screening practices among a national sample of primary care pediatricians

The objective of this study was to describe variations in hearing screening using a survey mailed to a national sample of primary care pediatricians prior to the 2003 American Academy of Pediatrics (AAP) hearing screening guidelines. Of the 390 primary care respondents, only 303 (78%) performed audiometry, routinely beginning at age 3 (32%), 4 (44%), or 5 (17%); 81% defined abnormal audiometry primarily as failure to hear at a specified decibel level: 15 dB hearing level (HL) (<1%), 16 to 20 dB HL (10%), 21 to 25 dB HL (23%), 26 to 30 dB HL (44%), 31 to 40 dB HL (16%), and more than 40 dB HL (6%). This study serves as a baseline for comparison with postguideline practices.

Success rate of newborn and follow-up screening of hearing using otoacoustic emissions

OBJECTIVE

During the last 6 years, and after a long period of pilot study, a universal newborn hearing screening program based on otoacoustic emissions is implemented in Iaso Maternity Hospital. Our purpose is to present the success rate of otoacoustic emission testing on discharge from the hospital and 1 month later.

METHODS

All full-term newborns who were screened during a period of 2 years and failed testing after one or more sessions of transiently evoked otoacoustic emissions, on discharge from the hospital, were included in the study. These newborns were retested approximately 1 month after discharge.

RESULTS

Twenty-five thousand and thirty-two newborns were examined in total. We found 534 (2.1%) 'refer' cases. Only 223 of them (41.8%) returned to retest in follow-up after 1 month. From the rescreening, 59 (2.3 per thousand) newborns failed in the test again and were referred for diagnostic audiological evaluation.

CONCLUSIONS

The rate of referrals was small, but efforts should be made to decrease it further. The final number of 'failures' found, approaches the expected rate of definitely diagnosed deafness reported from other settings. The main problem we have still to confront is the high missed to-follow-up rate.