Update on Newborn Hearing Screening NIDCD. National Goals for Hearing Screening (1-3-6) 1, 2 All...
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Transcript of Update on Newborn Hearing Screening NIDCD. National Goals for Hearing Screening (1-3-6) 1, 2 All...
Update on Newborn Update on Newborn Hearing ScreeningHearing Screening
NIDCD
National Goals for National Goals for Hearing Screening (1-3-Hearing Screening (1-3-
6)6)1, 21, 2 All infants will access hearing screening using All infants will access hearing screening using
a physiologic measure a physiologic measure – no later than 1 month of ageno later than 1 month of age
All infants not passing initial screening and All infants not passing initial screening and subsequent rescreening should have subsequent rescreening should have confirmatory audiological and medical confirmatory audiological and medical evaluations evaluations – no later than 3 months of ageno later than 3 months of age
All infants with confirmed permanent hearing All infants with confirmed permanent hearing loss should receive early intervention as soon loss should receive early intervention as soon as possibleas possible– no later than 6 months of ageno later than 6 months of age
Prerequisites for a Prerequisites for a Population Screening Population Screening
ProgramProgram Condition sufficiently frequent in Condition sufficiently frequent in
screened populationscreened population Condition serious or fatal without Condition serious or fatal without
interventionintervention Condition must be treatable or Condition must be treatable or
preventablepreventable Effective follow-up program Effective follow-up program
possiblepossible
YES
YES
YES
YES
Why is early identification of Why is early identification of hearing loss important?hearing loss important?
Hearing loss is the most common birth conditionHearing loss is the most common birth condition
Incidence of Congenital Conditions Incidence of Congenital Conditions
(Per 10,000)(Per 10,000)
0
5
10
15
20
25
30
35
Hearing loss Cleft lip orpalate
Downsyndrome
Limb defects Spina bifida Sickle cellanemia
PKU
Congenital Condition Type
Nu
mb
er
pe
r 1
0,0
00
Prevalence of Hearing LossPrevalence of Hearing Loss
Prevalence estimates vary across Prevalence estimates vary across studies studies
Estimated that 1 to 3 per 1000 infants Estimated that 1 to 3 per 1000 infants will have permanent sensorineural will have permanent sensorineural hearing losshearing loss3, 43, 4
– 1/1000 from the well baby nursery 1/1000 from the well baby nursery – 10/1000 from the NICU10/1000 from the NICU
Rate increases to 6/1000 by school Rate increases to 6/1000 by school ageage44
– Need for surveillanceNeed for surveillance
What does it sound like to What does it sound like to have a hearing loss?have a hearing loss?
Normal hearing
Mild hearing loss
Moderate hearing loss
Severe hearing loss
Why is early identification of Why is early identification of hearing loss important?hearing loss important?
Previous methods for detecting Previous methods for detecting hearing loss have been ineffectivehearing loss have been ineffective– High risk screening failed to identify High risk screening failed to identify
~ 50% of the infants with hearing ~ 50% of the infants with hearing lossloss
– Large retrospective cohort studyLarge retrospective cohort study5, 6: : mean age of diagnosis 21.6 monthsmean age of diagnosis 21.6 months
– Similar findings reported in USSimilar findings reported in US7,8,97,8,9
Newborn hearing Newborn hearing screening is effectivescreening is effective Large, good-quality cohort study Large, good-quality cohort study
conducted in UKconducted in UK1010
53,781 babies; 25,609 born during 53,781 babies; 25,609 born during NHS eraNHS era
2-step screening (OAE + ABR)2-step screening (OAE + ABR)– Sensitivity = 0.92Sensitivity = 0.92– Specificity = 0.98Specificity = 0.98
Lower refer rates with qualified Lower refer rates with qualified examinersexaminers1111
Why is early identification of Why is early identification of hearing loss important?hearing loss important?
Hearing loss is the most common Hearing loss is the most common birth conditionbirth condition
Previous methods for detecting Previous methods for detecting hearing loss have been ineffectivehearing loss have been ineffective
Undetected hearing loss can Undetected hearing loss can delay speech, language, social & delay speech, language, social & academic developmentacademic development
Vocabulary Development Vocabulary Development in Infantsin Infants12, 1312, 13
0
50
100
150
200
250
300
350
400
12 mos 14 mos 16 mos 18 mos 24 mos
Age
Nu
mb
er
of
Ex
pre
ss
ive
Wo
rds
NH Boys
NH Girls
Toddlers with Hearing Loss
Delays in babble also observed 14, 1514, 15
Reading Comprehension in Reading Comprehension in Children with Mild-Mod Loss Children with Mild-Mod Loss
1616
0
20
40
60
80
100
120
140
Grade 1 Grade 4
Academic Grade
Re
ad
ing
Co
mp
reh
en
sio
n S
tan
da
rd S
co
re
Normal Hearing
Hearing Loss
Why is early identification of Why is early identification of hearing loss important?hearing loss important?
Early identification and Early identification and intervention can make a intervention can make a differencedifference
Effects of Age of Effects of Age of Identification on Language Identification on Language DevelopmentDevelopment1717
Prospective, longitudinal study of Prospective, longitudinal study of early-identified infantsearly-identified infants
30 children with mild-profound hearing 30 children with mild-profound hearing loss (HL) compared to 96 normal loss (HL) compared to 96 normal hearing (NH) controlshearing (NH) controls
Children identified Children identified < < 3 months had 3 months had stronger language development at 12-stronger language development at 12-16 months than those identified > 3 16 months than those identified > 3 monthsmonths
Children with HL were delayed Children with HL were delayed compared to NH infantscompared to NH infants
Effects of Age of Identification Effects of Age of Identification on Language Developmenton Language Development1818
Language Quotients at Three Years of Age by Age of Identification Category
0
10
20
30
40
50
60
70
80
90
100
0-6 mos 7-12 mos 13-18 mos 19-24 mos 25-34 mos
Ages of Identification
La
ng
ua
ge
Qu
oti
en
t S
co
re Average range
Vocabulary at Age Five by Vocabulary at Age Five by Age of InterventionAge of Intervention1919
Id Age: 8%
Family
Involvement:
37%
Significant Predictors:
Average range
Evidence that Early Evidence that Early MattersMatters
8-year follow up to Wessex (UK) trial8-year follow up to Wessex (UK) trial1010
– 120 children with permanent HL (from 120 children with permanent HL (from population-based cohort of 157,000 infants)population-based cohort of 157,000 infants)
Speech-language outcomes at school age Speech-language outcomes at school age (Mean = 7.9 years)(Mean = 7.9 years)
Children with HL confirmed Children with HL confirmed < < 9 mos had 9 mos had better receptive and expressive language better receptive and expressive language scores than later identified children scores than later identified children – Speech scores were equivalent in the 2 Speech scores were equivalent in the 2
groupsgroups
American Academy of Pediatrics American Academy of Pediatrics (AAP)(AAP)
Endorsed implementation of Endorsed implementation of universal newborn hearing universal newborn hearing screening in 1999screening in 1999
Defined standards for:Defined standards for:– ScreeningScreening– Tracking & Follow-upTracking & Follow-up– Identification & InterventionIdentification & Intervention– Program EvaluationProgram Evaluation
Encouraged AAP Chapters to Encouraged AAP Chapters to provide leadership in physician provide leadership in physician education and newborn screening education and newborn screening in their statesin their states
Early Hearing Detection Early Hearing Detection and Intervention (EHDI)and Intervention (EHDI)
Endorsed by:Endorsed by:– AAP, National Institutes of Health, AAP, National Institutes of Health,
Maternal and Child Health, Centers for Maternal and Child Health, Centers for Disease Control, Joint Committee on Disease Control, Joint Committee on Infant Hearing & in 2008, the USPSTF Infant Hearing & in 2008, the USPSTF
As of 2005, all 50 states implemented As of 2005, all 50 states implemented statewide EHDI programsstatewide EHDI programs
As of 2006, an average of 95.7% of As of 2006, an average of 95.7% of newborns were screened nationallynewborns were screened nationally
Status of Hearing Status of Hearing ScreeningScreening
in Nebraska (as of 10/08)in Nebraska (as of 10/08)
99.5% of newborns are being 99.5% of newborns are being screened screened
68/69 hospitals are screening68/69 hospitals are screening Refer rate is 2.3%Refer rate is 2.3% 54 infants with permanent 54 infants with permanent
HL were diagnosed in 2007HL were diagnosed in 2007
Contact:Contact:[email protected]@dhhs.ne.go
vv
Hearing Screening Hearing Screening TechniquesTechniques
Otoacoustic emissions (OAE)Otoacoustic emissions (OAE)
Auditory brainstem response Auditory brainstem response (ABR)(ABR)
Two stage screening (OAE + ABR)Two stage screening (OAE + ABR)
Otoacoustic EmissionsOtoacoustic Emissions
Sounds are presented to the ear canal and a small microphone measures the response in the ear canal
Average test time is 5-15 minutes/baby
Auditory Brainstem Auditory Brainstem ResponseResponse
Sounds are presented and surface electrodes measure brainstem activity
Average test time 20 min/baby
OAE + ABROAE + ABR
All babies are screened using OAEs
Those babies who fail the OAE screening receive an ABR screening prior to leaving the hospital
Average test time/baby (25-35 min)
Reduces refer rate; useful when follow up is likely to be difficult or costly
Initial cost of equipment is higher than OAE or ABR screening alone, but follow-up costs are less
2007 JCIH Position on 2007 JCIH Position on ScreeningScreening22
NICUNICU– >5 days in NICU>5 days in NICU– ABR should be ABR should be
included to screen for included to screen for neural lossneural loss
– Rescreen BOTH ears, Rescreen BOTH ears, even if only one ear even if only one ear failsfails
– Non pass – refer to Non pass – refer to AudiologistAudiologist
– Readmission – Readmission – rescreen before rescreen before dischargedischarge
Well baby nurseryWell baby nursery– Screen with OAE or Screen with OAE or
ABRABR– Repeat screen when Repeat screen when
necessary before necessary before dischargedischarge
– When using 2 step When using 2 step protocol test order protocol test order should be OAE then should be OAE then ABRABR
– Rescreen BOTH ears, Rescreen BOTH ears, even if only one ear even if only one ear fails fails
Cost effectivenessCost effectiveness
Within each hospital, the Within each hospital, the optimum approach will depend optimum approach will depend upon the number of births/year, upon the number of births/year, the availability of trained the availability of trained personnel for testing 365 personnel for testing 365 days/year, follow-up services in days/year, follow-up services in the area, and expected loss to the area, and expected loss to follow-up rate.follow-up rate.
Screening CostsScreening Costs2222
Characteristics of a good Characteristics of a good screening programscreening program
Refer rate of 1.5-5.0% in well baby Refer rate of 1.5-5.0% in well baby nursery and slightly lower in the NICU nursery and slightly lower in the NICU (resulting from 2-stage screening in (resulting from 2-stage screening in the hospital)the hospital)– 5.0% = 400 babies per 8000 births5.0% = 400 babies per 8000 births
Ongoing training and monitoring Ongoing training and monitoring program for personnelprogram for personnel
Structured plan for follow up Structured plan for follow up Ability to track program performance Ability to track program performance
(important for quality assurance and (important for quality assurance and for JCAHO requirements)for JCAHO requirements)
What if a baby fails UNHS?What if a baby fails UNHS?
Failure rates range from 1.5-5.0% in Failure rates range from 1.5-5.0% in good screening programsgood screening programs
Most babies who fail the initial Most babies who fail the initial screening will actually have normal screening will actually have normal hearing hearing – For 10 babies that refer, 1 is expected For 10 babies that refer, 1 is expected
to have permanent hearing lossto have permanent hearing loss
System challenges: System challenges: Loss to Follow Up Loss to Follow Up2323
8 New York hospitals, 8 New York hospitals, – 28% infants who did not pass in-hospital 28% infants who did not pass in-hospital
screening failed to returnscreening failed to return– Loss to follow up is as high as 50% in Loss to follow up is as high as 50% in
some statessome states Return rates better for in-hospital fails Return rates better for in-hospital fails
than in-hospital missesthan in-hospital misses
Medical Home: Medical Home: Strategies to Promote Strategies to Promote
Follow Up Follow Up At prenatal visit, encourage families to At prenatal visit, encourage families to
identify you as follow-up care locationidentify you as follow-up care location Inform hospital to facilitate Inform hospital to facilitate
communication of results communication of results Provide checkbox on newborn well Provide checkbox on newborn well
child form/patient chart for hearing child form/patient chart for hearing screening results & risk factorsscreening results & risk factors
Set up tracking system for infants who Set up tracking system for infants who do not pass hearing screeningdo not pass hearing screening
Counseling ParentsCounseling Parents
Effective communication of results to Effective communication of results to families has an influence on follow up families has an influence on follow up behaviorsbehaviors
Balance between reassurance and Balance between reassurance and importance of follow up testingimportance of follow up testing
““Your child may or may not have a Your child may or may not have a hearing loss…but let’s be sure about it. If hearing loss…but let’s be sure about it. If further testing shows hearing loss, the further testing shows hearing loss, the earlier we get started helping the child, earlier we get started helping the child, the better.”the better.”
Counseling Parents Counseling Parents Following ScreeningFollowing Screening
Follow Up TestingFollow Up Testing
Referral for follow-up testing Referral for follow-up testing – Repeat OAE and/or ABR screeningRepeat OAE and/or ABR screening
If a hearing loss is still suspected…If a hearing loss is still suspected…– Referral to a Referral to a pediatricpediatric audiologist audiologist
Experienced in testing infants & childrenExperienced in testing infants & children Has appropriate equipment to test infantsHas appropriate equipment to test infants
– Frequency specific ABR to estimate Frequency specific ABR to estimate degree and configuration of hearing degree and configuration of hearing lossloss
Early testing can avoid need for sedationEarly testing can avoid need for sedation
Counseling Parents Counseling Parents Following DiagnosisFollowing Diagnosis
Components of a Components of a Comprehensive Audiological Comprehensive Audiological
EvaluationEvaluation History History Assessment of hearing sensitivity (ABR) Assessment of hearing sensitivity (ABR) Rule out middle ear pathology; refer to Rule out middle ear pathology; refer to
ENT physician if appropriate ENT physician if appropriate Initiate amplification Initiate amplification Refer to local early intervention Refer to local early intervention
programprogram Provide support via other parents of Provide support via other parents of
children with hearing losschildren with hearing loss PCP helps to coordinate child’s follow up PCP helps to coordinate child’s follow up
care in their practicecare in their practice
JCIH 2007 Follow Up JCIH 2007 Follow Up GuidelinesGuidelines22
EHDI systems should be family-EHDI systems should be family-centeredcentered
Families should have:Families should have:– Access to information on all Access to information on all
treatment optionstreatment options– Counseling regarding hearing lossCounseling regarding hearing loss
Child and family should have:Child and family should have:– Immediate access to hearing Immediate access to hearing
technologiestechnologies
AmplificationAmplification
Hearing aids can be Hearing aids can be fitted as young as 1 fitted as young as 1 month of agemonth of age
Importance of Importance of Intervention in Intervention in
OutcomesOutcomes
Early Identification needs to Early Identification needs to be paired with early, be paired with early,
appropriate and consistent appropriate and consistent interventions.interventions.
3 year old with moderate-severe loss: Inconsistent
Intervention
Child A
3 year old with moderate-severe loss: Consistent early
identification
Child B
3 year old with mild-moderate loss: Identified at 3 years, 3
monthsPre-intervention sample
Child C – 3 years
5 year old with mild-moderate loss: Identified at 3 years, 3
monthsPost- intervention sample
Child C – 5 years
Roles of the Medical HomeRoles of the Medical Home
Understand testing results at screening and Understand testing results at screening and diagnostic phases & implications for follow updiagnostic phases & implications for follow up
Assure follow-up screening; refer for Assure follow-up screening; refer for diagnostic and medical specialty evaluationsdiagnostic and medical specialty evaluations
Support family in understanding severity & Support family in understanding severity & type of hearing losstype of hearing loss
Refer to early intervention Refer to early intervention Offer partnership with parents to identify and Offer partnership with parents to identify and
develop a plan of health and habilitative caredevelop a plan of health and habilitative care
Optimal Surveillance in Optimal Surveillance in the Medical Home (JCIH, the Medical Home (JCIH,
2007)2007)22
At each visit consistent with AAP At each visit consistent with AAP periodicity schedule monitor for:periodicity schedule monitor for:– Auditory skills, middle ear statusAuditory skills, middle ear status– Developmental milestones (validated Developmental milestones (validated
global screening tool)global screening tool)– Parental concernsParental concerns
If concerns, refer for pediatric If concerns, refer for pediatric audiology and speech-language audiology and speech-language pathology evaluationspathology evaluations
Optimal Surveillance in Optimal Surveillance in the Medical Home (JCIH, the Medical Home (JCIH, 2007)2007)22
If hearing loss is diagnosed, refer siblings If hearing loss is diagnosed, refer siblings of infant for audiological evaluationof infant for audiological evaluation
Refer infants with any RISK indicators for Refer infants with any RISK indicators for audiological assessment by 24-30 audiological assessment by 24-30 months of agemonths of age
Carefully assess middle ear status at all Carefully assess middle ear status at all well child visits; refer for otologic well child visits; refer for otologic evaluation if persistent middle ear evaluation if persistent middle ear effusion lasts for 3 months+effusion lasts for 3 months+
Risk Indicators for permanent Risk Indicators for permanent congenital, delayed onset or congenital, delayed onset or
progressive hearing lossprogressive hearing loss22
Caregiver concerns* about hearing, speech, Caregiver concerns* about hearing, speech, language, developmentlanguage, development
Family history* of permanent childhood Family history* of permanent childhood hearing losshearing loss
NICU stay > 5 days or any of following NICU stay > 5 days or any of following (regardless of length of stay):(regardless of length of stay):
– ECMO assisted ventilation*ECMO assisted ventilation*– Ototoxic medications (gentimycin, tobramycin)Ototoxic medications (gentimycin, tobramycin)– Loop diuretics (furosemide, Lasix)Loop diuretics (furosemide, Lasix)– Hyperbilirubinemia reguiring exchange transfusionHyperbilirubinemia reguiring exchange transfusion
In Utero infections (cmv*, herpes, rubella, In Utero infections (cmv*, herpes, rubella, syphillis, toxoplasmosissyphillis, toxoplasmosis
* = greater risk for delayed onset HL
Risk Indicators for permanent Risk Indicators for permanent congenital, delayed onset or congenital, delayed onset or
progressive hearing lossprogressive hearing loss22
Caregiver concerns* Caregiver concerns* – about hearing, speech, language, developmentabout hearing, speech, language, development
Family history* Family history* – of permanent childhood hearing lossof permanent childhood hearing loss
NICU stay > 5 days or any of following NICU stay > 5 days or any of following (regardless of length of stay):(regardless of length of stay):– ECMO assisted ventilation*ECMO assisted ventilation*– Ototoxic medications (gentimycin, tobramycin)Ototoxic medications (gentimycin, tobramycin)– Loop diuretics (furosemide, Lasix)Loop diuretics (furosemide, Lasix)– Hyperbilirubinemia reguiring exchange Hyperbilirubinemia reguiring exchange
transfusiontransfusion
JCIH, 2007 * = greater risk for delayed onset HL
Risk Indicators for permanent Risk Indicators for permanent congenital, delayed onset or congenital, delayed onset or
progressive hearing lossprogressive hearing loss22
In Utero infections In Utero infections – CMV*, herpes, rubella, syphilis, CMV*, herpes, rubella, syphilis,
toxoplasmosistoxoplasmosis Craniofacial anomaliesCraniofacial anomalies Physical findings (e.g. white forelock)Physical findings (e.g. white forelock) Syndromes* involving hearing lossSyndromes* involving hearing loss
– Neurofibromatosis, osteopetrosis, Usher, Neurofibromatosis, osteopetrosis, Usher, Waardenburg, Alport, Pendred, Jervell & Waardenburg, Alport, Pendred, Jervell & Lange-NielsonLange-Nielson
* = greater risk for delayed onset HL
Risk Indicators for permanent Risk Indicators for permanent congenital, delayed onset or congenital, delayed onset or
progressive hearing lossprogressive hearing loss22
Neurodegenerative disordersNeurodegenerative disorders– Hunter syndromeHunter syndrome– Sensory motor neuropathies (Frieidrich Sensory motor neuropathies (Frieidrich
ataxia, Charcot-Marie-Tooth)ataxia, Charcot-Marie-Tooth) Culture positive postnatal infections Culture positive postnatal infections
associated with HL*associated with HL*– Herpes, varicella, meningitisHerpes, varicella, meningitis
Head trauma (basal skull, temporal Head trauma (basal skull, temporal bone)*bone)*
Chemotherapy*Chemotherapy*
* = greater risk for delayed onset HL
Medical WorkupMedical Workup
Complete prenatal & perinatal historyComplete prenatal & perinatal history Family Hx of onset of HL < age 30Family Hx of onset of HL < age 30 Physical for stigmata, ear tabs, cleftPhysical for stigmata, ear tabs, cleft
palate, cardiac, sketetal, palate, cardiac, sketetal, microcephalymicrocephaly
Refer to ENT/CT of temporal bonesRefer to ENT/CT of temporal bones Refer to Genetics and OphthalmologyRefer to Genetics and Ophthalmology Other: CMV, EKG, Developmental Other: CMV, EKG, Developmental
evaluationevaluation
CI Candidacy CriteriaCI Candidacy Criteria
3-6 month trial with hearing 3-6 month trial with hearing aids; lack of benefitaids; lack of benefit
Profound loss 90+dB (12 to Profound loss 90+dB (12 to 18 mos); >18 mos, Severe-18 mos); >18 mos, Severe-to-Profound 70 dB+to-Profound 70 dB+
No medical No medical contraindicationscontraindications
Rehab setting encouraging Rehab setting encouraging auditoryauditory
Family factors (motivation, Family factors (motivation, expectations)expectations)
Goals of Early Goals of Early InterventionIntervention Home based servicesHome based services Optimally, providers have experience & training with the Optimally, providers have experience & training with the
population and work to:population and work to:– Establish partnerships with familiesEstablish partnerships with families– Promote family competence & confidence in Promote family competence & confidence in
parenting childparenting child– Support family in providing a language-rich Support family in providing a language-rich
environment in everyday routinesenvironment in everyday routines– Support family to become informed decision makers Support family to become informed decision makers
for the childfor the child– Conduct ongoing assessments of outcomes Conduct ongoing assessments of outcomes
Adjust interventions as necessary to optimize outcomesAdjust interventions as necessary to optimize outcomes– Promote family access to formal and informal Promote family access to formal and informal
supportssupports– Provide culturally competent servicesProvide culturally competent services
Resources:Resources:
Early Early InterventionIntervention
Parent-to-ParentParent-to-Parent
Physician supportPhysician support
Contact State EHDI Contact State EHDI Coordinator – see Coordinator – see www.infanthearing.orgwww.infanthearing.org
www.nectac.org
www.handsandvoices.org www.beginningssvsc.com www.babyhearing.org
www.aap.org www.medicalhomeinfo.orwww.medicalhomeinfo.or
gg
Physician ResourcesPhysician Resources
http://www.medicalhomeinfo.org/screening/hearing.html
http://www.cdc.gov/ncbddd/dd/ddhi.htm
ALSO: hearing loss module on http://www.pedialink.org
www.babyhearing.orgwww.babyhearing.org
www.infanthearing.orgwww.infanthearing.org
www.infanthearing.org
Chapter Champion Chapter Champion ContactContact
For more information…For more information… Chapter Champion contact Chapter Champion contact
information and additional State information and additional State resources (like EHDI program) resources (like EHDI program) should be listed hereshould be listed here
ContributorsContributors
Mary Pat Moeller, Ph.D., BTNRHMary Pat Moeller, Ph.D., BTNRH Pat Stelmachowicz, Ph.D., BTNRHPat Stelmachowicz, Ph.D., BTNRH Don Uzendoski, M.D., AAP Chapter Don Uzendoski, M.D., AAP Chapter
Champion, BTNRHChampion, BTNRH Leisha Eiten, AUD, BTNRHLeisha Eiten, AUD, BTNRH Staci Gray, PA, BTNRHStaci Gray, PA, BTNRH Susan Wiley, M.D., AAP Chapter Susan Wiley, M.D., AAP Chapter
Champion, Cincinnati Children’s Champion, Cincinnati Children’s HospitalHospital
Roger Harpster, BTNRHRoger Harpster, BTNRH Diane Schmidt, BTNRHDiane Schmidt, BTNRH Skip Kennedy, BTNRHSkip Kennedy, BTNRH Dr. Karl White, Ph.D., NCHAMDr. Karl White, Ph.D., NCHAM Michelle Esquivel, AAPMichelle Esquivel, AAP
Project Supported by the National Institute on Deafness and Other Communication Disorders
(NIDCD/NIH) R25 DC04559; R25 DC006460
For additional information about this presentation orFor additional information about this presentation or
Universal NewbornUniversal Newborn Hearing ScreeningHearing Screening
contact: contact:
Boys Town National Research HospitalBoys Town National Research Hospital555 No. 30555 No. 30thth St. St.
Omaha, NE 68131Omaha, NE 68131
Dr. Mary Pat MoellerDr. Mary Pat Moeller(402) 452-5068(402) 452-5068
E-mail: [email protected]: [email protected]