Improving Newborn Hearing Screening and Follow-up

presented at the

Early Hearing Detection and Intervention:Making the Connections

Greensboro, North Carolina

by

Karl R. WhiteNational Center for Hearing Assessment and Management

www.infanthearing.orgApril 8, 2005

• Who is in charge?

Improving Newborn Hearing Screening and Follow-up

• Who is in charge?

• Communicating with parents

#1

Improving Newborn Hearing Screening and Follow-up

What every parent needs to

know

• Who is in charge?

• Communicating with parents

• Physician education

Improving Newborn Hearing Screening and Follow-up

Babies Diagnosed with Hearing Loss Are Not Referred to Some Medical Specialists As Often As Desired

Always or Often

Ophthalmological evaluation 0.6%

Genetic evaluation 8.7%

Otolaryngological evaluation 74.4%

Assume a newborn for whom you are caring is diagnosed with a moderate to profound bilateral hearing loss. If no other indications are present, would you refer the baby for a(n):

Responses of 1375 physicians in 21 states

When can an infant be fit with hearing aids?

0

5

10

15

20

25

30

# of physicians

birth1 mo 2mos

3mos

4-5mos

6mos

7 to11

mos

12to18

mos

19+mos

Percentage of Physicians

American Academy of Pediatrics

• Who is in charge?

• Communicating with parents

• Physician education

• Selecting and training screeners– Who can be a good screener?

– Don’t train more than you need

– Regular supervision

Improving Newborn Hearing Screening and Follow-up

• Who is in charge?

• Communicating with parents

• Physician education

• Selecting and training screeners

• Keeping refer rates low

Improving Newborn Hearing Screening and Follow-up

Keeping Refer Rates Low

• Schedule screening when babies are in best behavioral state

• Make a second effort prior to discharge

• Minimize noise and confusion

• Regular supervision and assistance

• Swaddling

• Back-up equipment and supplies

• Who is in charge?

• Communicating with parents

• Physician education

• Selecting and training screeners

• Keeping refer rates low

• What is your target?

Improving Newborn Hearing Screening and Follow-up

AABRScreening

Comprehensive HearingEvaluation Before 6 Months

of AgeFail Fail

Pass Pass

Discharge Discharge

OAE Screening Prior toHospital Discharge

Does a 2-stage (OAE/AABR) newborn hearing screening protocol miss babies with mild hearing loss?

Study SampleComprehensive Audiological Assessment at 8-12 months of age

Comparison Group

Research Procedures• Nationally representative sites with successful

screening programs recruited

• From a birth cohort of 86,634 newborns who were screened for hearing, 1524 parents of newborns who failed OAE and passed AABR were enrolled

– Baby and family data collected

– Contact every 2 months

• Follow-up diagnostic assessment at 8-12 months of age

– Visual Reinforcement Audiometry, OAE, and Tymp

– Responses measured to 15 dB at 1K, 2K, and 4K

– Data were collected for 973 children (64%)

How Many Additional Babies with Permanent Hearing Loss were Identified?

Comparison Group(Fail OAE/ Fail AABR)

Study Group(Fail OAE/ Pass AABR)

Total

Number of Babies 158 21 179Prevalence per 1,000 1.82 .55* 2.37

Represents 23% of all babies with PHL in birth cohort

*Adjusted for proportion of OAE fails that enrolled

Degree of Hearing Loss* in Study and Comparison Group Babies

Mild Moderate

Severe through

ProfoundTotal

Infants (20-40 dB) (41-70 dB) (>70 dB) w/PHL

15 5 1 21

71.4% 23.8% 4.8% 100.0%31 64 63 158

19.6% 40.5% 39.6% 100.0%

46 69 64 179

25.7% 38.5% 35.8% 100.0%As measured in the worse ear

Total

Study Group

Comparison Group

80.3%

28.6%

Conclusions A substantial number of babies with permanent hearing

loss at 9 months of age will pass A-ABR during newborn screening

Best estimate is .55 per thousand or 23% of all babies with permanent hearing loss

Mostly mild sensorineural hearing loss

Impossible to determine whether this is congenital or late-onset

About 45% of these would be identified if all babies with risk factors or contralateral refer ears were followed, but this may not be practical

Screening for permanent hearing loss should extend into early childhood (e.g. physician’s offices, early childhood programs)

Emphasize to families and physicians that passing hospital-based hearing screening does not eliminate the need to vigilantly monitor language development.

Screening program administrators should ensure that the stimulus levels of equipment used are consistent with the degree of hearing loss they want to identify

The relative advantages and disadvantages of the two-stage (OAE/AABR) protocol need to be carefully considered for individual circumstances

Recommendations

• Who is in charge?

• Communicating with parents

• Physician education

• Selecting and training screeners

• Keeping refer rates low

• What is your target?

• Tracking and Follow-up

Improving Newborn Hearing Screening and Follow-up

Tracking and Data Management

Screening

Research

Diagnosis Intervention

Program Improvementand Quality Assurance

Rate Per 1000 of Permanent Childhood Hearing Loss in UNHS Programs

Location of Program(Time)

CohortSize

Primary Screening Technique

Prevalence Per 1000 of

Hearing Loss*

% of Refers Lost to

Follow-up

New JerseyBarsky-Firkser & Sun, 1997

(1/93 - 12/95)

15,749 ABR 3.30 41%

New YorkPrieve, 2000

(1/96 - 12/96)

27,938 OAE & AABR

1.96 23%

ColoradoMehl & Thomson, 1998

(1/92 - 12/96)

41,976 AABR 2.56 52%

TexasFinitzo, et al., 1998

(1/94 - 6/97)

54,228 OAE 2.15 31%

HawaiiJohnson, et. al, 1997

(1/94 - 6/97)

9,605 OAE 4.15 2%

Tracking "Refers" is a Major Challenge(continued)

Initial Rescreen Births Screened Refer Rescreen Refer

Rhode Island 53,121 52,659 5,397 4,575 677 (1/93 - 12/96) (99%) (10%) (85%) (1.3%)

Hawaii 10,584 9,605 1,204 991 121(1/96 - 12/96) (91%) (12%) (82%) (1.3%)

New York 28,951 27,938 1,953 1,040 245 (1/96-12/96) (96.5%) (7%) (53%) (0.8%)

• Who is in charge?

• Communicating with parents

• Physician education

• Selecting and training screeners

• Keeping refer rates low

• What is your target?

• Tracking and Follow-up

• Continuous Screening

Improving Newborn Hearing Screening and Follow-up

MCHB’s National Agenda for Children with

Special Health Care Needs

Core outcome #3:

All children will be screened early and continuously for special health care needs

Continuous screening opportunities

As EHDIs increasingly turn their attentions to enhancing follow-up and continuous screening, they are identifying important community partners –

one of them is

Head Start

Status of Head Start Hearing Screening Practices

Head Start’s “Performance Standards” reflect a long-standing commitment to hearing screening: All children are to receive a hearing screen within 45 days of enrollment; however:

Most Grantees rely on subjective screening methods such as hand clapping, bell ringing, and parent questionnaires to screen children 0 – 3 years of age

Most Grantees unaware that Otoacoustic Emissions (OAE) technology, used widely in newborn hearing screening programs, can also be used successfully in early childhood settings.

Pilot program in WA, OR, and UT from 2001-2004

69 Migrant, American Indian, and Early Head Start sites trained in WA, OR, and UT

3486 children screened

The Hearing Head Start Project

OAE Screening/Referral Outcomes

78 children identified with a hearing loss or disorder:

6 permanent hearing loss

63 serious otitis media requiring treatment

2 treated for occluded Pressure Equalization tubes

7 treated for excessive ear wax

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