Newborn hearing screening protocol in tuscany region

Useful Clinical Criteria for Identifying Neonates with Congenital Cytomegalovirus Infection at Birth in the Context of an Expanded Targeted Screening Program

Cytomegalovirus (CMV) is the leading infectious cause of brain defects and neurological dysfunctions, including sensorineural hearing loss (SNHL). Targeted screening in neonates failing the hearing screen is currently recommended in Italy according to national guidelines. However, SNHL may not be present at birth; also, congenital CMV (cCMV) may manifest with subtle signs other than SNHL. Therefore, the inclusion of additional criteria for cCMV screening appears clinically valuable. Starting January 2021, we have implemented expanded targeted cCMV screening at our center, with testing in case of maternal CMV infection during pregnancy, inadequate antenatal care, maternal HIV infection or immunosuppression, birthweight and/or head circumference < 10th centile, failed hearing screen, and prematurity. During the first three years of use of this program (2021-2023), 940 (12.3%) of 7651 live-born infants were tested. The most common indication was birthweight < 10th centile (n = 633, 67.3%). Eleven neonates were diagnosed as congenitally infected, for a prevalence of 1.17% (95%CI 0.48-1.86) on tested neonates and of 0.14% (95%CI 0.06-0.23) on live-born infants. None of the cCMV-infected newborns had a failed hearing screen as a testing indication. Implementation of an expanded cCMV screening program appears feasible and of clinical value.

The Role of Bone-Anchored Hearing Devices and Remote Microphones in Children with Congenital Unilateral Hearing Loss

Congenital unilateral hearing loss (UHL) represents a contemporary audiologic challenge. Children with UHL can struggle with understanding speech in noise, localizing sounds, developing language, and maintaining academic performance, leading to low self-esteem, anxiety, and decreased social support. Two specific conditions related to UHL in children are single-sided deafness (SSD) and unilateral auris atresia (UAA). This was a retrospective observational study on a group of children with UHL. The Simplified Italian Matrix Sentence Test was used for the assessment of speech reception threshold (SRT) in different conditions: speech and noise from the front (S0N0), speech at 45° from the side of the better ear and noise at 45° from the opposite side (SbNw), and vice versa (SwNb). Each test was conducted unaided, with a bone-anchored hearing device (BAHD), and with a remote microphone (RM) system. The use of a BAHD and RM led to an improvement in SRT in S0N0 and SwNb conditions. The SSD subgroup demonstrated significant benefits with both devices in SwNb, and the UAA subgroup from the use of BAHD in S0N0. In conclusion, the study underscores the potential benefits of both devices in enhancing speech perception for UHL children, providing insights into effective intervention strategies for these challenging cases.

The Audiological Follow-Up of Children with Symptomatic Congenital Cytomegalovirus Infection: An Experience in Two Italian Centers

BACKGROUND

Congenital cytomegalovirus (cCMV) infection is the leading cause of non-hereditary sensorineural hearing loss in children. While about 10% of children reportedly display symptoms at birth, 85-90% of cCMV infection cases are asymptomatic. However, 10-15% of these asymptomatic infants may later develop hearing, visual, or neurodevelopmental impairments. This study aimed to evaluate the impact of cCMV infection on newborns' hearing function with a particular emphasis on progressive and late-onset cases.

METHODS

This study is a retrospective chart analysis with longitudinal character and was conducted in two Italian centers: Center 1 (from 1 November 2007 to 31 December 2021) and Center 2 (from 1 January 2012 to 31 December 2021). Data collected included newborn hearing screening results, characterization of hearing loss (unilateral/bilateral, degree of impairment), and audiological follow-up.

RESULTS

The cohort consisted of 103 children (42% males, 58% females). In total, 28 children presented with hearing impairment; 71.4% (20 out of 28) of the cases of hearing loss were severe/profound, with 35.7% of the cases due to unilateral hearing loss. Out of twenty-eight, six experienced progression of hearing loss and four had late-onset hearing loss.

CONCLUSIONS

In the absence of universal cCMV screening, hearing screening at birth for cCMV remains a critical factor for early diagnosis. A significant percentage of children affected by cCMV with normal audiological evaluations at birth is easily lost to follow-up. Close collaboration between neonatologists, pediatricians, and audiological services is fundamental to ensure timely diagnosis and treatment of cCMV-related hearing loss.

Early cochlear implantation in prelingual profound hearing loss in Italy, analyzed by means of a social media survey

OBJECTIVE

To assess newborn hearing screening (NHS) impact on timing of cochlear implant (CI) surgery of patients with prelingual bilateral profound hearing impairment (BPHI), in order to evaluate whether the NHS ultimately serves the needs of the target population in Italy.

METHODS

An online questionnaire was created to survey subjects affected by prelingual BPHL born between 1990 and 2018. Questions focused on age at BPHI diagnosis, first and second CI surgery (if performed), and the region in which the surgery was performed. The survey was distributed to potential participants via social media communities used by hearing impaired people or their family members for sharing advice and offering support. Responses were analyzed using descriptive statistics.

RESULTS

Among the 318 respondents who completed the questionnaire, 276 (87%) reported having chosen CI surgery, 2/3 of them bilaterally. In the vast majority (97%) of cases the CI is used on a daily basis. Most of the people residing in the center (65%) and southern Italy (71%) had to move from their region of residence to perform the surgery. Late CI surgery was associated with failure to perform NHS (p = 0.007), birth before 2011 (p = 0.009), definitive diagnosis of BPHI after 6 months of life (p = 0.002), and progressive hearing impairment (p < 0.001).

CONCLUSION

The worldwide scientific approval of the NHS as the current best opportunity for early diagnosis and CI treatment for prelingual BPHI is confirmed by what patients and families reported via the online questionnaire used for this study. In recent years, early bilateral cochlear implantation has become increasingly available in Italy, but late diagnosis, progressive hearing loss, failure to perform the NHS and lack of follow-up are still open questions. A large proportion of families had to move from the region of residence to have their child undergo CI surgery, revealing inequalities in terms of geographical disparities. Social media has proved to be a valuable, fast and inexpensive tool for gathering information on the effectiveness of health prevention programs, involving a large sample of individuals in a short amount of time.

A systematic review of newborn and childhood hearing screening around the world: comparison and quality assessment of guidelines

Background

This study aimed to assess the quality of global guidelines or consensus statements for newborn and childhood hearing screening, as well as to compare various guidelines between other countries and China.

Methods

A PROSPERO registered systematic review (number CRD42021242198) was conducted. Multiple electronic databases and government websites including PubMed, EMBASE, Web of Science, CENTRAL, Cochrane Library, and BMJ Best Practice were searched from inception until May 2021. The latest national and international guidelines, consensus statements, technical specifications, and recommendations regarding newborn or childhood hearing screening that were published in Chinese or English medical journals or elsewhere with the full version available online. The following information was extracted independently by two reviewers for comparative analysis: titles, authors, publication year, country, the source organization, and main key recommendations using systems for assigning the level of evidence and strength of recommendations. The quality of the guidelines was assessed by three independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition. Intraclass correlation coefficients (ICCs) were calculated to assess among-reviewer agreement.

Results

We assessed 15 newborn and 6 childhood hearing screening guidelines, respectively. Most newborn guidelines recommend the 1–3-6 guidelines and pre-discharge screening; however, the specific screening times differ. 93.33% of newborn hearing guidelines recommend “primary screening-re-screening-diagnosis-intervention” for well-babies while 73.33% of the guidelines recommend "initial screening-diagnosis-intervention" for newborns in neonatal intensive care unit (NICU); 33.33% of the newborn hearing guidelines recommended initial screening coverage of > 95% while 46.66% did not mention it. Further, 26.66% of the newborn hearing guidelines recommended a referral rate to diagnosis within 4% while 60% did not mention it. Regarding childhood hearing screening guidelines, the screening populations differed across guidelines (age range: 0–9 years); most guidelines recommend pediatric hearing screening for all preschoolers. Only 50% of the guidelines specify screening and re-screening techniques, including pure-tone hearing screening, OAE, tympanometry, and others. The “Clarity of Presentation” domain achieved the highest mean score, and the lowest was “Editorial Independence” both in newborn and childhood guidelines. Overall score of newborn hearing screening guidelines ranged from 3 (2018 Europe) to 7 (2019 America), with an average score of 5.33. Average score of childhood hearing screening guidelines was 4.78, with the score ranging from 4 (2017 England, 2012 Europe, 2016 WHO) to 6.67 (2011 America). ICC analysis revealed excellent agreement across 21 guidelines (> 0.75).

Conclusions

These findings indicated newborn hearing screening guidelines had superior quality over childhood ones. Comparative analysis suggested that recommendations of the Chinese newborn and pediatric hearing screening protocols are consistent with the mainstream international opinion. Moreover, this analysis demonstrated that “Editorial Independence” and “Stakeholder Involvement” have the greatest opportunities for improvement. These results may help to advance the quality of hearing screening guidelines in clinical practice and guide evidence-based updates.

A Rare Case of Perrault Syndrome with Auditory Neuropathy Spectrum Disorder: Cochlear Implantation Treatment and Literature Review

Perrault syndrome (PRLTS) is a rare autosomal recessive disorder characterised by ovarian failure in females and sensorineural hearing loss (SNHL) in both genders. In the present paper we describe a child affected by PRLTS3, due to CLPP homozygous mutations, presenting auditory neuropathy spectrum disorder (ANSD) with bilateral progressive SNHL. This is the first case reported in the literature of an ANSD in PRLTS3. CLPP is a nuclear encoded mitochondrial protease directed at the mitochondrial matrix. It is encoded on chromosome 19. This protease participates in mitochondrial protein quality control by degrading misfolded or damaged proteins, thus maintaining the normal metabolic function of the cell. In PRLTS3, the peptidase activity of CLPP is suppressed. Neurological impairments involved in PRLTS3 suggest that the pathogenic mutations in CLPP might trigger a mitochondrial dysfunction. A comprehensive description of the clinical and audiological presentation, as well as the issues related to cochlear implant (CI) procedure and the results, are addressed and discussed. A brief review of the literature on this topic is also provided.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Performance and characteristics of the Newborn Hearing Screening Program in Campania region (Italy) between 2013 and 2019

Purpose

Universal newborn hearing screening (UNHS) in the first month of life is crucial for facilitating both early hearing detection and intervention (EHDI) of significant permanent hearing impairment (PHI). In Campania region, UNHS has been introduced in 2003 by the Regional Council Resolution and started on January 2007. The aim of this paper is to update a previous article describing the performance of the program since its implementation in the period between 2013 and 2019.

Methods

A longitudinal retrospective study was carried at the Regional Reference Center III on 350,178 babies born in the analysis period. The paper reports the main results of overall coverage, referral rate, lost-to-follow-up rate,yield for PHI and shall determine various risk factor associations with hearing impairment

Results

In Campania region, 318,878 newborns were enrolled at I level, with a coverage rate of 91.06%, 301,818 (86.18%) Well Infant Nurseries (WIN) and 17,060 (5.35%) Neonatal Intensive Care Unit (NICU) babies. PHI was identified in 413 children, 288 (69.73%) bilaterally and 125 (30.26%) unilaterally. The overall cumulative incidence rate of PHI was 1.29 per 1000 live-born infants (95% CI 1.17–1.42) with a quite steady tendency during the whole study period.

Conclusions

This study confirms the feasibility and effectiveness of UNHS in Campania region also in a setting with major socioeconomic and health organization restrictions.The program meets quality benchmarks to evaluate the progress of UNHS. Nowadays, it is possible to achieve an early diagnosis of all types of HL avoiding the consequences of hearing deprivation.

Clinical practice guidelines on newborn hearing screening: A systematic quality appraisal using the AGREE II instrument

INTRODUCTION

Several guidelines and consensus statements have been produced and disseminated for the detection and management of newborn hearing loss. However, to date, the quality and methodologic rigor of these screening and management protocols have not been appraised.

OBJECTIVE

To identify and evaluate existing guidelines and consensus statements for the detection and management of neonatal hearing loss.

METHODS

A comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources was conducted until August 2020. The quality of these guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered satisfactory quality if they scored >60%, and intraclass correlation coefficients (ICC) were calculated to assess agreement among the appraisers.

RESULTS

Twelve guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality', and the remaining were 'average' or 'low quality'. The 'Scope and Purpose' domain achieved the highest mean score (91.3% ± 5.8%), and lowest was 'Rigor of Development' (35.8% ± 19.1%). ICC analysis showed good to very good agreement across all domains (0.63-0.95).

CONCLUSION

These findings highlight the variability in methodologic quality of guidelines and consensus statement for the detection and management of neonatal hearing loss. These results may help to improve the reporting of future guidelines and guide the selection and use of these guidelines in clinical practice.

Methodological quality of clinical guidelines for universal newborn hearing screening

AIM

To review existing guidelines for universal newborn hearing screening (UNHS), identify those that provide comprehensive and clear recommendations on the subject, and provide a brief overview.

METHOD

A scoping literature review was performed in PubMed, the Guidelines International Network library, and national guideline databases to identify guidelines on newborn hearing screening developed or updated between 2004 and 2019. The quality of the guidelines was checked with the Checklist for the Quality Assessment of Guidelines (AGREE II).

RESULTS

Six guidelines met all the inclusion criteria. All six were based on the 1-3-6 benchmark (screening completed by 1mo, audiological diagnosis by 3mo, enrolment in early intervention by 6mo). However, the guidelines varied in terms of their recommendations for the application of screening methods, role of health professionals in the screening process, and quality. Based on the AGREE II score, flexibility, adaptability, and foundation role for all other guidelines, the 2019 guidelines of the Joint Committee on Infant Hearing position statement were identified as the most appropriate to be recommended for adaptation by countries or programmes.

INTERPRETATION

The diversity in the existing guidance can be confusing for countries and institutions that are planning to develop universal hearing screening programmes. As more countries and organizations develop their newborn hearing screening programmes, they will need examples to emulate. This review provides an evaluation of the quality, comprehensiveness, and applicability of existing clinical guidelines that can serve as a facilitator for countries, institutions, or organizations in their planning and implementation of a UNHS programme.

Congenital cytomegalovirus infection and audiological follow-up: electrophysiological auditory threshold before 3 months of age as a predictor of hearing outcome at 3 years of age

OBJECTIVE

We aimed to evaluate whether electrophysiological auditory thresholds (EATs) before 3 month of age, as assessed by the auditory brainstem responses (ABR) test and the auditory steady state responses (ASSR) test, can predict hearing outcome at 3 years of age among children born with congenital cytomegalovirus (cCMV) infection.

STUDY DESIGN

Audiological assessment was performed before 3 months of age, and every 6 months thereafter until 3 years of age, in a population of 63 children (126 ears). EATs before 3 months of age and at 3 years of age were compared.

RESULT

No ear with an EAT of ≤30 dBHL (i.e. normal hearing) before 3 months of age showed worsening EATs at 3 years of age.

CONCLUSION

An EAT of ≤30 dBHL obtained by ABR and ASSR tests before 3 months of age is predictive of a normal hearing at 3 years of age in children born with cCMV.

Newborn hearing screening at the Neonatal Intensive Care Unit and Auditory Brainstem Maturation in preterm infants

OBJECTIVES

Aim of this study is to report and discuss the results of 4 years of Newborn hearing screening (NHS) program at the Neonatal Intensive Care Unit (NICU), particularly evaluating the clinical ABR results.

METHODS

Retrospective study. NHS data from NICU newborns, admitted for ≥5 days, in the period from January 1st^, 2013 and December 31st^, 2016, were retrieved and analyzed. NHS results were classified as following: (i) "pass" when both ears for both the a-TEOAE (automated Transient-Evoked Otoacoustic Emissions) and the a-ABR (automated Auditory Brainstem Response) protocol resulted as "pass"; (ii) "fail" when one ear, at either one of the two performed tests resulted as "fail"; (iii) "missing" when the newborns were not tested with both protocols. All "fail" and "missing" newborns were retested (with both tests): in the case of a second "fail" result, a clinical ABR was performed within a period of 3 months.

RESULTS

A total of 1191 newborns were screened. From those, 1044/1191 resulted as "pass", 108/1191 as "fail", and 39/1191 as "missing". During the re-testing of these 147 newborns, 43 were assigned as "missing", 63 were assigned as "pass" (showing bilaterally a wave V identifiable within 30 dB nHL) and 25 failed the retest and/or did not present an identifiable wave V within 30 dB nHL. Among the 147 retested infants, we identified a group of 16 subjects who resulted as NHS "refer" and who, during the audiological follow-up, showed either: (i) a unilateral or bilateral wave V identifiable over 30 dB nHL, at the first clinical ABR assessment; or (ii) a bilateral wave V identifiable within 30 dB nHL, in a following clinical ABR test during the first year of life. These 16 subjects were defined to have an 'Auditory Brainstem Maturation' issue.

CONCLUSIONS

A possible "maturation" of the ABR response (and therefore of the auditory pathway) has been hypothesised in 16 out of 1191 infants (1.3%). A delay of the auditory pathway maturation in preterm babies compared to term newborns has already been suggested in the literature. A possible delay of the NHS retest could be considered, in selected cases, with significant savings in economic resources and parental anxiety.

Diagnosis of congenital CMV infection via DBS samples testing and neonatal hearing screening: an observational study in Italy

Background

Congenital Cytomegalovirus (cCMV) is the most common cause of non-genetic hearing loss in childhood. A newborn hearing screening program (NHSP) is currently running in Italy, but no universal cCMV nor statewide hearing-targeted CMV screening programs have been implemented yet.

This observational monocentric study was aimed at estimating the rate of cCMV infections identified by CMV-DNA analysis on Dried Blood Spots (DBS) samples in deaf children identified via NHSP in Northern Italy in the period spanning from 2014 to 2018.

Methods

Children with a confirmed diagnosis of deafness and investigated for CMV-DNA by nucleic acid extraction and in-house polymerase-chain reaction (PCR) on stored newborns screening cards (DBS-test) were included in this study. Deafness was defined by a hearing threshold ≥20 decibel (dB HL) by Auditory Brainstem Responses (ABR); all investigated DBS samples were collected within 3 days of life.

Results

Overall, 82 children were included (median age: 3.4 months; lower-upper quartiles: 2–5.3 months; males: 60.9%). Most of them (70.7%) presented bilateral hearing loss with a symmetrical pattern in 79.3% of the cases. ABR thresholds were ≥ 70 dB HL (severe/profound deafness) in 46.5% of children. Among all tested children, 6.1% resulted positive for cCMV. The rate of severe/profound deafness was statistically higher in children with cCMV infection.

Conclusions

The addition of DBS-test to the NHSP allowed the identification, in their first months of life, of a cCMV infection in 6.1% of children who had failed NHS. The introduction of a targeted CMV screening strategy could help clinicians in the differential diagnosis and in the babies’ management. DBS samples can be considered a “universal newborns biobank”: their storage site and duration should be the subject of political decision-making.

Universal newborn hearing screening in the Lazio region, Italy

Background

The introduction of Universal Newborn Hearing Screening (UNHS) programs has drastically contributed to the early diagnosis of hearing loss in children, allowing prompt intervention with significant results on speech and language development in affected children. UNHS in the Lazio region has been initially deliberated in 2012; however, the program has been performed on a universal basis only from 2015. The aim of this retrospective study is to present and discuss the preliminary results of the UNHS program in the Lazio region for the year 2016, highlighting the strengths and weaknesses of the program.

Methods

Data from screening facilities in the Lazio region for year 2016 were retrospectively analyzed. Data for Level I centers were supplied by the Lazio regional offices; data for Level II and III centers were provided by units that participated to the study.

Results

During 2016, a total of 44,805 babies were born in the Lazio region. First stage screening was performed on 41,821 children in 37 different birth centers, with a coverage rate of 93.3%. Of these, 38.977 (93.2%) obtained a “pass” response; children with a “refer” result in at least one ear were 2844 (6.8%). Data from Level II facilities are incomplete due to missing reporting, one of the key issues in Lazio UNHS. Third stage evaluation was performed on 365 children in the three level III centers of the region, allowing identification of 70 children with unilateral (40%) or bilateral (60%) hearing loss, with a prevalence of 1.6/1000.

Conclusions

The analysis of 2016 UNHS in the Lazio region allowed identification of several strengths and weaknesses of the initial phase of the program. The strengths include a correct spread and monitoring of UNHS among Level I facilities, with an adequate coverage rate, and the proper execution of audiological monitoring and diagnosis among Level III facilities. Weakness, instead, mainly consisted in lack of an efficient and automated central process for collecting, monitoring and reporting of data and information.