Comparison of Newborn Hearing Screening in Well-Baby Nursery and NICU: A Study Applied to Reduce Referral Rate in NICU

Evaluation of the current situation and quality of neonatal hearing screening from hearing screening practitioners' perspective: a cross-sectional study

BACKGROUND

In recent years, neonatal hearing screening (NHS) has gained rapid traction in both developed and developing nations. However, the efficacy of these efforts depends on comprehensive standardization across all screening facets. This study aimed to assess the status and quality of NHS by investigating the knowledge, attitudes, beliefs, and practices of hearing screening practitioners regarding NHS.

METHODS

A cross-sectional survey was conducted, and an online questionnaire based on the knowledge-attitude/belief (A/B)-practice model was distributed to all NHS practitioners in Luzhou, western China. Valid questionnaires were examined and uniformly graded.

RESULTS

A total of 63 valid questionnaires were collected. The practitioners were mainly female (96.83%), with nursing backgrounds (63.49%), and undergraduate degrees (66.67%). Most had ≤5 years of experience (74.60%) and had junior/intermediate titles (93.65%). The NHS within the Luzhou area started in 2006 with provincial institutions, expanding to 42 institutions by 2022. Statistically significant correlations were observed between the A/B score and the conducting years of each NHS institution (p < .05) as well as between the Knowledge (K) and Practice (P) scores (p < .01). No significant correlation was found between the K score, P score, A/B score, and working years of practitioners (p > .05), or in the total score of NHS institutions at different levels or in different counties by one-way ANOVA (p > .05).

CONCLUSIONS

It has been 17 years since the first medical institution in Luzhou launched NHS, and the overall performance of practitioners from different institutions has been consistent in terms of their knowledge, attitudes, or level of practice. However, there is room for further improvement in both the professional development of individuals and aspects related to work, such as health education and long-term follow-up.

Referral rate and false-positive rates in a hearing screening program among high-risk newborns

AIM

More studies exploring referral rates and false-positive rates are needed to make hearing screening programs in newborns better and cost-effective. Our aim was to study the referral and false-positivity rates among high-risk newborns in our hearing screening program and to analyze the factors potentially associated with false-positive hearing screening test results.

METHODS

A retrospective cohort study was done among the newborns hospitalized at a university hospital from January 2009 to December 2014 that underwent hearing screening with a two-staged AABR screening protocol. Referral rates and false-positivity rates were calculated and possible risk factors for false-positivity were analyzed.

RESULTS

4512 newborns were screened for hearing loss in the neonatology department. The referral rate for the two-staged AABR-only screening was 3.8% with false-positivity being 2.9%. Our study showed that the higher the birthweight or gestational age of the newborn, the lower the odds of the hearing screening results being false-positive, and the higher the chronological age of the infant at the time of screening, the higher the odds of the results being false-positive. Our study did not show a clear association between the mode of delivery or gender and false-positivity.

CONCLUSION

Among high-risk infants, prematurity and low-birthweight increased the rate of false-positivity in the hearing screening, and the chronological age at the time of the test seems to be significantly associated with false-positivity.

Hearing loss in neonates and infants

Hearing in neonates and infants is crucial for their development of language and communication skills. Unless hearing loss is appropriately managed early, it can cause a significant socioeconomic burden considering its detrimental impact on the child's development and its common nature. It is also the most common congenital sensory deficit, with an approximate incidence of 1.5 per 1,000 newborns. Its etiologies are heterogeneous: genetic causes are reportedly involved in up to 80% of cases, while congenital cytomegalovirus infection is the leading environmental factor contributing to congenital hearing loss. The introduction of newborn hearing screening using automated auditory brainstem response and/or automated otoacoustic emission in many developed countries has helped detect and manage hearing loss early. Current auditory rehabilitation options such as cochlear implantation implementing cutting-edge technologies can treat almost all degrees of hearing loss, emphasizing the importance of early hearing detection and intervention. Rapidly developing genetic diagnostic technologies and future cutting-edge treatment options, including gene therapy, will shed light on the future management of hearing loss in neonates and infants.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

BACKGROUND

An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.

METHODS

Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.

RESULTS

Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.

CONCLUSION

Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Children With Unilateral Hearing Loss After Newborn Hearing Screening in Taiwan

PURPOSE

We explored the intervention characteristics and language outcomes of children with unilateral hearing loss (UHL) in Taiwan after the implementation of universal newborn hearing screening (UNHS) to highlight changes in attitudes and actions toward hearing-related treatments.

METHOD

Data of 132 children with UHL in birth cohorts from 2012 to 2019 were included. This retrospective study examined differences in age at identification, hearing aid (HA) fitting, and seeking supportive services. Commonly requested attributes of services, reasons for HA rejection, and children's language performance were investigated.

RESULTS

The age at identification decreased from 50.3 months in 2012 to 2.6 months in 2019. Similar trends of declining age were obtained for the age at HA fitting and age at first service contact. In addition, 40% of the parents did not seek support until the child became older (M = 30.5 months) and showed more noticeable behaviors related to hearing loss, and only 64% of the children were consistent HA users. Children with UHL enrolled in the intervention programs approximated the average language performance of the assessment norm; however, they showed depressed language levels when compared to the norm group at the 75th percentile.

CONCLUSIONS

UNHS had a positive impact on early identification and intervention in children with UHL. Compared to parents of children with all types of hearing loss, parents of children with UHL seemed to be more uncertain about aural habilitation at the early stage.

Neonatal Screening for Congenital Hearing Loss in the North of Jordan; Findings and Implications

BACKGROUND

Congenital hearing loss is one of the important illnesses that affect newborns. Early diagnosis and treatment are a challenge for medical authorities in developing countries to improve children's functional, intellectual, emotional, and social abilities. We aimed to study the prevalence of congenital hearing loss in northern Jordan community and identify factors that could affect hearing screening protocol.

METHODS

Prospective cross-sectional study of 1595 infants born in our hospital underwent hearing screening tests. Totally, 104 were tested in NICU and the rest examined in the nursery room using Otoacoustic emission (OAE) test as a primary testing tool. The patients were followed in the three hearing screening phases. Factors affecting screening results were studied and analyzed.

RESULTS

The total number of newborns who didn't pass the first OAE test in one or both ears were 90 (5.6%); 69 from the nursery group and 21 from the NICU group. In the 2^nd screening phase 21 (23.3%) didn't attend the appointment. Sixty-four passed the second screening OAE test. Five newborns (5.6%) had a second refer result in one or both ears and referred for a diagnostic ABR test. Three infants passed the test and two found to have bilateral hearing loss.

CONCLUSIONS

Hearing screening test is conducted via a 3-phases-protocol. OAE is used in the first two phases and ABR in the third phase. Hearing results is significantly affected for infants admitted to NICU. The following factors increase OAE fail response: mechanical ventilation for more than 5 days, Hyperbilirubinemia, associated congenital anomalies. Mode of delivery doesn't have statistical significance on hearing screening results.

[Follow-up II of newborn hearing screening : Evaluation of a follow-up II facility after implementation of newborn hearing screening in Germany]

BACKGROUND

With the implementation of newborn hearing screening, evaluation in terms of quality and goal achievement was required. The present study evaluates a follow-up II facility from 2009 to 2016.

METHODS

Data of 2705 newborns were retrospectively evaluated. The annual number of patients was analyzed, as well as the median age at first presentation, at diagnosis, and at treatment, each according to the reason for presentation and the diagnosis.

RESULTS

From 2009 to 2016, the number of presented newborns increased by 91.4%. Newborns with abnormal initial screening or risk factors were presented significantly later than those for initial screening (median 5.3 and 8.0 vs. 4.6 weeks, respectively; p < 0.001). Permanently or transiently hearing-impaired patients were presented and diagnosed significantly later than those with normal hearing (age at initial presentation 6.1 and 7.6 vs. 5.4 weeks, p < 0.01 and p < 0.001, respectively; age at diagnosis 11.4 and 23.1 vs. 5.9 weeks, respectively; p < 0.001). Permanent hearing loss was treated at the age of 14.1 weeks. From 2009 to 2014, the age at first presentation and at diagnosis increased and subsequently mostly decreased until 2016.

CONCLUSION

The age at first presentation and at diagnosis depends on the reason for presentation and on the diagnosis. Despite increasing patient numbers, the Joint Federal Committee (Gemeinsame Bundesausschuss, G‑BA) targets were met due to effective and efficient organizational structuring of the follow-up II facility. However, early admission to a follow-up II facility is a prerequisite for the success of newborn hearing screening.

Quality measures of a multicentre universal newborn hearing screening program in Malaysia

OBJECTIVE

To evaluate and discuss the outcomes of the universal newborn hearing screening program conducted at four public hospitals in Malaysia.

METHOD

A retrospective analysis of the universal newborn hearing screening database from each hospital was performed. The database consisted of 28,432 and 30,340 screening results of babies born in 2015 and 2016, respectively. Quality indicators (coverage rate, referral rate, return for follow-up rate, and ages at screening and diagnosis) were calculated.

RESULTS

Overall coverage rate across the four hospitals was 75% in 2015 and 87.4% in 2016. Over the two years, the referral rates for the first screening ranged from 2.7% to 33.93% with only one hospital achieving the recommended benchmark of <4% in both years. The return for follow-up rates for each participating hospital was generally below the recommended benchmark of ≥95%. The mean age at screening was 3.9 ± 1.2 days and 3.3 ± 0.4 days, respectively. The mean age at diagnosis for 70 infants diagnosed with permanent hearing loss was 4.7 ± 0.7 months in 2015 and 3.6 ± 0.9 months in 2016.

CONCLUSIONS

Quality measures for the universal newborn hearing screening program in four public hospitals in Malaysia were lower than the required standards. Nevertheless, some quality indicators showed statistically significant improvements over the two years. Next steps involve identifying and implementing the best practice strategies to improve the outcome measures and thus the quality of the program.

Analysis of the Risk Factors Associated with Hearing Loss of Infants Admitted to a Neonatal Intensive Care Unit: A 13-Year Experience in a University Hospital in Korea

Early detection of hearing loss in neonates is important for normal language development, especially for infants admitted to the neonatal intensive care unit (NICU) because the infants in NICU have a higher incidence of hearing loss than healthy infants. However, the risk factors of hearing loss in infants admitted to the NICU have not been fully acknowledged, especially in Korea, although they may vary according to the circumstances of each country and hospital. In this study, the risk factors of hearing loss in NICU infants were analyzed by using the newborn hearing screening (NHS) and the diagnostic auditory brainstem response (ABR) test results from a 13-year period. A retrospective chart review was performed using a list of NICU infants who had performed NHS from 2004 to 2017 (n = 2404) in a university hospital in Korea. For the hearing loss group, the hearing threshold was defined as 35 dB nHL or more in the ABR test performed in infants with a 'refer' result in the NHS. A four multiple number of infants who had passed the NHS test and matched the age and gender of the hearing loss group were taken as the control group. Various patient factors and treatment factors were taken as hearing loss related variables and were analyzed and compared. From the 2404 infants involved, the prevalence of hearing loss was 1.8% (n = 43). A comparison between the hearing loss group (n = 43) and the control group (n = 172) revealed that history of sepsis, peak total bilirubin, duration of vancomycin use, days of phototherapy, and exposure to loop-inhibiting diuretics were significantly different, and can be verified as significant risk factors for hearing loss in NICU infants.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

Outcomes of Automated Auditory Evoked Potential Performed in Different Settings and the Factors Associated with Referred Cases

Introduction  For the population with risk factors for hearing loss, the first option to assess the hearing status is the performance of the automated brainstem auditory evoked potential (BAEP) test because of its efficacy in identifying retrocochlear hearing loss. Objective  To verify the outcomes of automated BAEP performed in different settings as well as the factors associated with the prevalence of hearing impairment. Methods  Cross-sectional study conducted from October of 2014 to May of 2015. The sample consisted of 161 infants with at least one risk factor for hearing loss who underwent automated BAEP during the hospital stay or at the outpatient clinic. After 30 days, the altered cases were referred for BAEP diagnosis. Results  One hundred and thirty-eight infants (86%) had a result of "pass" and 23 (14%) of "failure" in the automated BAEP. There was no statistically significant difference in the rate of "referred" results between examinations performed in different settings. The infants' ages did not influence the number of abnormal cases. All of the 23 infants who presented a "referred" result in the automated BAEP, unilateral or bilateral, were sent for BAEP diagnosis, and out of these, 9 (39%) remained with at least some degree of alteration. The average age of diagnosis was 2.7 months. Conclusion  The results of the automated BAEP were similar when performed during hospitalization or after discharge. Neither the age at the examination nor the gender of the patient influenced the prevalence of hearing loss.

Universal newborn hearing screening using A-TEOAE and A-ABR: The experience of a large public hospital

BACKGROUND

Universal newborn hearing screening (UNHS) aims to identify hearing loss in the early postnatal period; prompt detection of bilateral or unilateral hearing loss is mandatory for timely intervention.

METHODS

This retrospective study reports the results of the first two years of a UNHS program on 4,719 newborns in a large public Italian hospital. Screening was divided into two levels: automated transient otoacoustic emissions were used for first level; automated auditory brainstem response for second level. Second level included children with a "refer" response at first level and babies with a family history for hearing loss or other risk factors. Hearing loss diagnosis was made using clinical auditory brainstem response.

RESULTS

During first level, 254 (5.4% ) newborns were "refer". At retest, 130 (51.1% ) babies were PASS and 48 (18.8% ) were "refer". 76 babies dropped out (29.9% ). 146 babies (3.1% ) were referred to the second level: 48 for a "refer" response at first level and 98 for a PASS response but potential hearing loss due to risk factors. 24 babies dropped out (16.4% ). Out of 122 newborns tested in the second level, 105 (86.1% ) had a PASS response and 17 (13.9% ) were "refer". Our screening protocol identified 7 (0.14% ) babies with profound hearing loss; 5 had unilateral and 2 had bilateral hearing loss. 2 babies dropped out at diagnostic level (11.8% ).

CONCLUSIONS

A correct and early diagnosis of hearing loss is mandatory to prevent permanent consequences; the spread of hearing screening programs is the optimal solution to reach this goal.

MBD2 Regulates Th17 Cell Differentiation and Experimental Severe Asthma by Affecting IRF4 Expression

Th17 cells and IL-17 participate in airway neutrophil infiltration characteristics in the pathogenesis of severe asthma. Methyl-CpG binding domain protein 2 (MBD2) expression increased in CD4⁺ T cells in peripheral blood samples of asthma patients. However, little is known about that epigenetic regulation of MBD2 in both immunological pathogenesis of experimental severe asthma and CD4⁺ T cell differentiation. Here, we established a neutrophil-predominant severe asthma model, which was characterized by airway hyperresponsiveness (AHR), BALF neutrophil granulocyte (NEU) increase, higher NEU and IL-17 protein levels, and more Th17 cell differentiation. In the model, MBD2 and IRF4 protein expression increased in the lung and spleen cells. Under overexpression or silencing of the MBD2 and IRF4 gene, the differentiation of Th17 cells and IL-17 secretion showed positive changes. IRF4 protein expression showed a positive change with overexpression or silencing of the MBD2 gene, whereas there was no significant difference in the expression of MBD2 under overexpression or silencing of the IRF4 gene. These data provide novel insights into epigenetic regulation of severe asthma.