|
Policy Statement |
Pediatrics |
Volume 103, Number 2 |
February 1999, pp 527-530
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Newborn and Infant Hearing Loss: Detection and Intervention
(RE9846)
AMERICAN ACADEMY OF PEDIATRICS
Task Force on Newborn and Infant Hearing
This statement endorses the implementation of universal newborn hearing
screening. In addition, the statement reviews the primary objectives, important
components, and recommended screening parameters that characterize an effective
universal newborn hearing screening program.
ABBREVIATIONS. UNHSP, universal newborn hearing screening program; EOAE,
evoked otoacoustic emissions; ABR, auditory brainstem response; CDC, Centers for
Disease Control and Prevention.
Significant hearing loss is one of the most common major abnormalities
present at birth and, if undetected, will impede speech, language, and cognitive
development.1-7 Significant bilateral hearing loss is present in ~1
to 3 per 1000 newborn infants in the well-baby nursery population, and in ~2 to
4 per 100 infants in the intensive care unit population. Currently, the average
age of detection of significant hearing loss is ~14 months. The American Academy
of Pediatrics supports the statement of the Joint Committee on Infant Hearing
(1994), which endorses the goal of universal detection of hearing loss in
infants before 3 months of age, with appropriate intervention no later than 6
months of age.8 Universal detection of infant hearing loss requires
universal screening of all infants. Screening by high-risk registry alone (eg,
family history of deafness) can only identify ~50% of newborns with significant
congenital hearing loss.9,10 Reliance on physician observation and/or
parental recognition has not been successful in the past in detecting
significant hearing loss in the first year of life.
To justify universal screening, at least five criteria must be met:
- An easy-to-use test that possesses a high degree of sensitivity and
specificity to minimize referral for additional assessment is available.
- The condition being screened for is otherwise not detectable by clinical
parameters.
- Interventions are available to correct the conditions detected by
screening.
- Early screening, detection, and intervention result in improved outcome.
- The screening program is documented to be in an acceptable cost-effective
range.11,12
Although additional studies are necessary, review of both published and
unpublished data indicates that all five of these criteria currently are
achievable by effective universal newborn hearing screening programs (UNHSP).
5,13,15-28 Therefore, this statement endorses the implementation of
universal newborn hearing screening. In addition, this statement reviews the
primary objectives, important components, and recommended screening parameters
that characterize an effective UNHSP.
The Academy recognizes that there are five essential elements to an effective
UNHSP: initial screening, tracking and follow-up, identification, intervention,
and evaluation.13,14 The child's physician and parents, working in
partnership, make up the child's medical home and play an important role in each
of these elements of a UNHSP.29
SCREENING11,13,14
The following are guidelines for the screening element of a UNHSP:
- Universal screening has as its goal that 100% of the target population,
consisting of all newborns, will be tested using physiologic measures in both
ears. A minimum of 95% of newborns must be screened successfully for it to be
considered effective.16,19,21
- The methodology should detect, at a minimum, all infants with significant
bilateral hearing impairment, ie, those with hearing loss
>35-decibel in the better ear.1,16,19
- The methodology used in screening should have a false-positive rate, ie,
the proportion of infants without hearing loss who are labeled incorrectly by
the screening process as having significant hearing loss, of <3%.
The referral rate for formal audiologic testing after screening should not
exceed 4%.16,17,19-21
- The methodology used in screening ideally should have a false-negative
rate, ie, the proportion of infants with significant hearing loss missed by
the screening program, of zero.21,23
- Until a specific screening method(s) is proved to be superior, the Academy
defers recommendation as to a preferred method. Currently, acceptable
methodologies for physiologic screening include evoked otoacoustic emissions
(EOAE) and auditory brainstem response (ABR), either alone or in combination.
Both methodologies are noninvasive, quick (<5 minutes), and easy to
perform, although each assesses hearing differently. EOAE measures sound waves
generated in the inner ear (cochlea) in response to clicks or tone bursts
emitted and recorded via miniature microphones placed in the external ear
canals of the infant. Although EOAE screening is even quicker and easier to
perform than ABR, EOAE may be affected by debris or fluid in the external and
middle ear, resulting in referral rates of 5% to 20% when screening is
performed during the first 24 hours after birth. ABR measures the
electroencephalographic waves generated in response to clicks via three
electrodes pasted to the infant's scalp. ABR screening requires the infant to
be in a quiet state, but it is not affected by middle or external ear debris.
Referral rates <3% may be achieved when screening is performed during the
first 24 to 48 hours after birth. Referral rates <4% are generally
achievable with EOAE combined with automated ABR in a two-step screening
system or with automated ABR alone.16,17,19-21 In a two-step system
using EOAE as the first step, referral rates of 5% to 20% for repeat screening
with ABR or EOAE may be expected. The second screening may be performed before
discharge or on an outpatient basis within 1 month of age. Screening should be
conducted before discharge from the hospital whenever possible.
- Each birthing hospital should establish a UNHSP with a designated medical
(physician) director and sufficient staff to perform the following:
- Develop the screening protocol and select the screening method(s).
- Provide appropriate training and monitoring of the performance of staff
responsible for performing hearing screening.
- Provide the parents or guardians information concerning the screening
procedure, costs, potential risks of hearing loss, and the benefits of early
detection and intervention.
- Establish a system that ensures confidentiality and allows the parents or
guardians the opportunity to decline hearing screening. In most institutions,
general hospital consent obtained at time of admission is considered to be
inclusive of routine care, such as newborn hearing screening.
- Ensure that all individuals performing hearing screening are trained
properly in the performance of the tests, the risks including psychological
stress for the parents, infection control practices, and the general care and
handling of infants in hospital settings according to established hospital
policies and procedures.30
- Establish clear guidelines for responsibility of documenting the results
of the screening procedure.
- Develop mechanisms for communicating results of screening in a sensitive
and timely manner to the parents and the child's physician(s). If repeat
screening is necessary after discharge from the hospital, ensure that
appropriate follow-up is provided.
- Work with local, state, and national monitoring systems to identify all
cases of significant hearing loss occurring in infants designated initially as
free of hearing impairment by the UNHSP (false-negatives).
- Secure funding for the program. Funding through third-party reimbursement
is essential to cover the costs of the UNHSP, including the initial screen(s),
as well as of diagnostic and intervention services. The cost of complete
screening in statewide programs ranges from ~$7 to $26 per infant
screened.13 Additional studies (some of which are ongoing) are
necessary to quantify costs of tracking, diagnostic, and intervention
services.26-28
- Collect critical performance data to ensure that each UNHSP meets the
criteria specified in this statement. These data should be reported in a
regular and timely manner to a statewide central monitoring program.
TRACKING AND FOLLOW-UP13-15,26-28
The following are guidelines for the tracking and follow-up elements of a
UNHSP:
- Universal screening has as its goal that there will be 100% follow-up of
all infants referred for formal audiologic assessment and for all infants not
screened initially in the birthing hospital whose parents did not refuse
screening. A minimum of 95% successful follow-up is required for a UNHSP to be
considered an effective screening program.
- State departments of health, in coordination with programs mandated by
Part C of the Individuals with Disabilities Education Act, should:
- Establish and maintain a central monitoring system for all hearing
screening programs within the state. Critical performance data, including
number of infants born; the proportion of all infants screened; the referral
rate; the follow-up rate; the false-positive rate; and the false-negative
rate should be collected in a timely manner.
- Establish and maintain a tracking program that monitors all referrals
and misses. Monitoring should ensure that children with significant hearing
loss are not missed, ie, all children designated as free of hearing loss by
the UNHSP, but who are later detected to have significant hearing loss, are
identified by the statewide tracking program.
- Develop mechanisms for communicating results of follow-up activities
with the parents/guardians and the child's physician(s), audiologist, and
speech language therapist.29
- Ensure that hearing screening is performed on all out-of-hospital
births.
- Report the screening performance parameters of individual hospital-based
UNHSPs within the state in a timely manner.
- Report critical performance data of each UNHSP (without personal
identifiers) to a national Early Hearing Detection and Intervention
monitoring program established by the Centers for Disease Control and
Prevention (CDC).
IDENTIFICATION AND INTERVENTION13-15,26-28
The following are guidelines for the identification and intervention element
of a UNHSP:
- Universal screening has as its goal that 100% of infants with significant
congenital hearing loss shall be identified by 3 months of age and shall have
appropriate and necessary intervention initiated by 6 months of age.5-7
- Appropriate and necessary care for the infant with significant hearing
loss should be directed and coordinated by the child's physician within the
medical home, with support from appropriate ancillary services.29
- A regionalized approach to identification and intervention for infants
with significant hearing loss is essential, ensuring access for all children
with significant hearing loss to appropriate expert services. It is recognized
that professionals with demonstrated competency to provide expert services in
the identification and intervention of significant hearing loss in young
infants are not available in every hospital or community. The child's
physician, within the medical home, working with the state department of
health must ensure that every infant with significant hearing loss is referred
to the appropriate professional(s) within the regionalized system.
- It is anticipated that there will be increased demand for qualified
personnel to provide age-appropriate identification and intervention services
for young infants with significant hearing loss. As a result, there will be a
need for the training and education of additional expert care providers.
EVALUATION13-15,26-28
The following are guidelines for the evaluation element of a UNHSP:
- The UNHSPs should be evaluated on an ongoing and regular basis by the
state monitoring system for performance with regard to parameters enumerated
in "Screening" above.
- Tracking and follow-up should be evaluated on an ongoing and regular basis
by the state monitoring system, as well as through a national monitoring
system to be established by the CDC.
- Intervention services should be evaluated on an ongoing and regular basis
by the state department of health to ensure that sufficient expert services
are available for children identified with significant hearing loss, that the
services are accessible to the children in need, and that outcomes from
interventions provided are effective.
OTHER RECOMMENDATIONS AND ISSUES
The following are additional recommendations of the Academy for developing a
UNHSP:
- The Academy recommends that each American Academy of Pediatrics chapter
assume a leadership role in state-based efforts to promote optimal
implementation of UNHSPs. Effective statewide programs require broad-based
support and collaboration. Collaboration should include (but not be limited
to) appropriate professional organizations, parent advocacy groups, deaf and
hard-of-hearing adults, physicians, audiologists, speech and language
therapists, nurses, administrators, payers, legislators, and state departments
of health and special education.
- The Academy shall identify, develop, and disseminate educational materials
regarding effective hearing screening programs.13
- To promote additional research and the development of the needed
infrastructure to provide universal newborn hearing screening, the Academy
recommends the following:
- The National Institutes of Health support ongoing research to improve
the efficacy of screening, identification, and intervention.
- The Health Resources and Services Administration promote the development
of a state-based early hearing loss identification and intervention network.
- The CDC establish and maintain a national monitoring and evaluation
program for early hearing loss identification and intervention.
Physicians should provide recommended hearing screening, not only during
early infancy but also through early childhood for those children at risk for
hearing loss (eg, history of trauma, meningitis) and for those demonstrating
clinical signs of possible hearing loss.9,14 Although most hearing
loss in children is congenital (ie, present at birth), a significant portion of
hearing loss is acquired after birth.2-4 Regardless of the age of
onset, all children with hearing loss require prompt identification and
intervention by appropriate professionals with pediatric training and
expertise.
- TASK FORCE ON NEWBORN AND INFANT HEARING, 1998-1999
- Allen Erenberg, MD
- AAP Delegate to Joint Committee on Infant Hearing
- James Lemons, MD
- Chairperson, AAP Committee on Fetus and Newborn
- Calvin Sia, MD
- Chairperson, Project Advisory Committee for the Medical Home
Program
for Children With Special Needs
- David Tunkel, MD
- Chairperson, AAP Section on
Otolaryngology--Bronchoesophagology
- Philip Ziring, MD
- Chairperson, AAP Committee on Children With Disabilities
- CONSULTANTS
- Mike Adams, MD
- Associate Director for Program Development, Centers for
Disease Control and Prevention
- June Holstrum, PhD
- Behavioral Scientist, Centers for Disease Control and
Prevention
- Merle McPherson, MD
- Director, Division of Services for Children With Special
Health Care Needs,
Maternal and Child Health Bureau
- Nigel Paneth, MD
- Professor of Pediatrics and Epidemiology and Chairperson of
the Department of Epidemiology
at Michigan State University
- Bonnie Strickland, PhD
- Chief, Habilitative Services, Division of Services for
Children With Special Health Care Needs,
Maternal and Child
Health Bureau
REFERENCES
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Williams & Wilkins; 1984:89
- Centers for Disease Control and Prevention. Serious hearing impairment
among children aged 3-10 years — Atlanta, Georgia, 1991-1993. MMWR.
1997;46:1073-1076
- Parving A. Detection of the infant with congenital/early acquired hearing
disability. Acta Otolaryngol Suppl (Scand). 1991;482:111-116.
Discussion, p 117
- Sorri M, Rantakallio P. Prevalence of hearing loss at the age of 15 in a
birth cohort of 12000 children from northern Finland. Scand Audiol.
1985;14:203-207
- Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and
later-identified children with hearing loss. Pediatrics.
1998;102:1161-1171
- Robinshaw HM. Early intervention for hearing impairment Br J
Audiol. 1995;29:315-334
- Robinshaw HM. The pattern of development from non-communicative behavior
to language by hearing-impaired infants. Br J Audiol. 1996;30:177-198
- AAP, Joint Committee on Infant Hearing 1994 position statement.
Pediatrics. 1995;95:152-156
- Davis A, Wood S. The epidemiology of childhood hearing impairment: factors
relevant to planning of services. Br J Audiol. 1992;26:77-90
- Watkin PM, Baldwin M, McEnery G. Neonatal at risk screening and the
identification of deafness. Arch Dis Child. 1991;66:1130-1135
- Fletcher RH, Fletcher SW, Wagner EW. Clinical Epidemiology: The
Essentials. 2nd ed. Baltimore, MD: Williams & Wilkins; 1988
- Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology: A Basic
Science for Clinical Medicine. 2nd ed. Boston, MA: Little, Brown and
Company; 1991
- Spivak LG, ed. Universal Newborn Hearing Screening. New York, NY:
Thieme; 1998
- Davis A, Bamford J, Wilson I, Ramkalawan T, Forshaw M, Wright S. A
critical review of the role of neonatal hearing screening in the detection of
congenital hearing impairment. Health Technol Assess Winch Engl.
1997;1:i-iv, 1-176
- White KR. Realities, myths, and challenges of newborn hearing screening in
the United States. Am J Audiol. 1996;6:95-99
- Barsky-Firsker L, Sun S. Universal newborn hearing screenings: a
three-year experience. Pediatrics. 1997;99(6).
www:pediatrics.org/cgi/content/full/99/6/e4. Accessed October 8, 1998
- Downs MP. Universal newborn hearing screening—the Colorado story. Int J
Pediatr Otorhinolaryngol. 1995;32:257-259
- Lutman ME, Davis AC, Fortnum HM, Wood S. Field sensitivity of targeted
neonatal hearing screening by transient evoked otoacoustic emissions. Ear
Hear. 1997;18:265-276
- Mason JA, Herrmann KR. Universal infant hearing screening by automated
auditory brainstem response measurement. Pediatrics. 1998;101:221-228
- Mehl AL, Thomson V. Newborn hearing screening: the great omission.
Pediatrics. 1998;101(1). www:pediatrics.org/cgi/content/full/101/1/e4.
Accessed October 8, 1998
- Vohr BR, Carty LM, Moore PE, Letourneau K. The Rhode Island Hearing
Assessment Program: experience with statewide hearing screening (1993-1996).
J Pediatr. 1998;133:353-357
- Watkin PM. Outcomes of neonatal screening for hearing loss by otoacoustic
emission. Arch Dis Child Fetal Neonat Educ. 1996;75:F158-F168
- Watkin PM. Neonatal otoacoustic emission screening and the identification
of deafness. Arch Dis Child Fetal Neonat Educ. 1996;74:F16-F25.
Comments
- Windmill IM. Universal screening of infants for hearing loss: further
justification. J Pediatr. 1998;133:318-319
- Johnson JL, Mauk GW, Takekawa KM, Simon PR, Sia CJ, Blackwell PM.
Implementing a statewide system of services for infants and toddlers with
hearing disabilities. Semin Hearing. 1993;14:105-119
- Downs MP. The case for detection and intervention at birth. Semin
Hearing. 1994;15:76-83
- Stevens JC, Hall DM, Davis A, Davies CM, Dixon S. The costs of early
hearing screening in England and Wales. Arch Dis Child. 1998;78:14-19
- Maxon AB, White KR, Vohr BR, Behrens TR. Using transient evoked
otoacoustic emissions for neonatal hearing screening. Br J Audiol.
1993;27:149-153
- AAP. The medical home. Pediatrics. 1992;90:5. Statement addendum.
AAP News. November 1993
- American Academy of Pediatrics/American College of Obstetricians and
Gynecologists. Guidelines for Perinatal Care. 4th ed. Washington, DC:
American Academy of Pediatrics/American College of Obstetricians and
Gynecologists; 1997
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The recommendations in this statement do not indicate an exclusive
course of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
Copyright © 1999 by the American Academy of Pediatrics.
No part of this statement may be reproduced in any form or by any
means without prior written permission from the American Academy of Pediatrics
except for one copy for personal use.
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