Transcript Improving Newborn Hearing Screening and Follow

Improving Newborn Hearing Screening
and Follow-up
presented at the
Early Hearing Detection and Intervention:
Making the Connections
Greensboro, North Carolina
by
Karl R. White
National Center for Hearing Assessment and Management
www.infanthearing.org
April 8, 2005
Improving Newborn Hearing Screening
and Follow-up
• Who is in charge?
Improving Newborn Hearing Screening
and Follow-up
• Who is in charge?
• Communicating with
parents
#1
What every parent
needs to know
Improving Newborn Hearing Screening
and Follow-up
• Who is in charge?
• Communicating with
parents
• Physician education
Babies Diagnosed with Hearing Loss Are Not Referred to
Some Medical Specialists As Often As Desired
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):
Always or Often
Ophthalmological evaluation
0.6%
Genetic evaluation
8.7%
Otolaryngological evaluation
74.4%
Responses of 1375 physicians in 21 states
When can an infant be fit
with hearing aids?
30
25
# of of
Percentage
physicians
Physicians
20
15
10
5
0
birth 1 mo
2
3
4-5
6
7 to
mos mos mos mos 11
mos
12 19+
to mos
18
mos
American Academy of Pediatrics
Improving Newborn Hearing Screening
and Follow-up
• 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
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
Improving Newborn Hearing Screening
and Follow-up
• Who is in charge?
• Communicating with
parents
• Physician education
• Selecting and training
screeners
• Keeping refer rates low
• What is your target?
Does a 2-stage (OAE/AABR) newborn
hearing screening protocol miss
babies with mild hearing loss?
Comparison Group
OAE Screening Prior to
Hospital Discharge
Pass
Fail
AABR
Screening
Pass
Fail
Comprehensive Hearing
Evaluation Before 6 Months
of Age
Study Sample
Comprehensive Audiological
Assessment at 8-12 months of age
Discharge
Discharge
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
Study Group
(Fail OAE/ Fail AABR)
(Fail OAE/ Pass AABR)
Number of Babies
158
21
179
Prevalence 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
Total
Degree of Hearing Loss* in Study and
Comparison Group Babies
28.6%
(20-40 dB)
(41-70 dB)
(>70 dB)
Total
Infants
w/PHL
15
5
1
21
71.4%
23.8%
4.8%
100.0%
31
64
63
158
19.6%
40.5%
46
69
25.7%
38.5%
Mild
Study Group
Comparison Group
Total
Severe
through
Moderate Profound
39.6% 100.0%
64
179
35.8% 100.0%
As measured in the worse ear
80.3%
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
Recommendations
 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 twostage (OAE/AABR) protocol need to be carefully
considered for individual circumstances
Improving Newborn Hearing Screening
and Follow-up
• 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
Tracking and Data Management
Research
Program Improvement
and Quality Assurance
Screening
Diagnosis
Intervention
Rate Per 1000 of Permanent Childhood Hearing
Loss in UNHS Programs
Location of Program
(Time)
Cohort
Size
Primary
Screening
Technique
Prevalence
Per 1000 of
Hearing Loss*
% of Refers
Lost to
Follow-up
New Jersey
15,749
ABR
3.30
41%
27,938
OAE &
AABR
1.96
23%
41,976
AABR
2.56
52%
54,228
OAE
2.15
31%
9,605
OAE
4.15
2%
Barsky-Firkser & Sun, 1997
(1/93 - 12/95)
New York
Prieve, 2000
(1/96 - 12/96)
Colorado
Mehl & Thomson, 1998
(1/92 - 12/96)
Texas
Finitzo, et al., 1998
(1/94 - 6/97)
Hawaii
Johnson, et. al, 1997
(1/94 - 6/97)
Tracking "Refers" is a Major Challenge
(continued)
Initial
Refer
Rescreen
Rescreen
Refer
Births
Screened
Rhode Island
(1/93 - 12/96)
53,121
52,659
(99%)
5,397
(10%)
4,575
(85%)
677
(1.3%)
Hawaii
(1/96 - 12/96)
10,584
9,605
(91%)
1,204
(12%)
991
(82%)
121
(1.3%)
New York
(1/96-12/96)
28,951
27,938
(96.5%)
1,953
(7%)
1,040
(53%)
245
(0.8%)
Improving Newborn Hearing Screening
and Follow-up
• 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
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 longstanding 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.
The Hearing Head Start Project
 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
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
www.infanthearing.org
www.babyhearing.org