INFANT HEARING SCREENING
INTRODUCTION:
A
direct comparison of guidelines issued by USPSTF, OMAR, CTFPHC, AAP and ICSI
for infant hearing screening are provided in the tables, below. Table 1 compares the
scope and the content of each guideline. Table 2 compares
specific recommendations made by each organization regarding universal newborn
infant screening prior to hospital discharge (USPSTF, OMAR, AAP); on-going
hearing screening following hospital discharge as a means of surveillance
(USPSTF, OMAR, CTFPHC, ICSI); and screening methods (USPSTF, OMAR, CTFPHC, AAP,
ICSI). The rating schemes used to classify the strength of the evidence
supporting USPSTF, CTFPHC and ICSI recommendations, are provided at the end of Table 2. Table 3 compares the
potential benefits and harms outlined by the guideline developers associated
with the implementation of each of the guidelines.
The
following comparisons are restricted to recommendations for infants and young
children (< 3 years); they do not include recommendations for older
children, adolescents, or adults. The guidelines issued by USPSTF, OMAR and AAP
specifically address the issue of screening for hearing impairment in infants.
USPSTF also evaluates hearing screening across the life span. CTFPHC and ICSI
address all preventive/screening services, including routine infant hearing
screening, that should be included in periodic health examinations. Because
this synthesis focuses on hearing screening in infants, only those
recommendations related to infant screening in the USPSTF guideline, and
hearing screening in the CTFPHC and ICSI guidelines, are presented.
Note,
the CTFPHC guideline considers the recommendations released by OMAR. USPSTF
presents recommendations released by OMAR (1993) and CTFPHC (1994), as well as
others.
Following
the content comparison in Tables 1-3, the areas of agreement and difference
among the guidelines are identified. In general, the sensitivity (proportion of
infants with hearing loss identified by the screening test) and the specificity
(the proportion of infants without hearing loss that pass the screening test)
of different screening methods as well as the cost-effectiveness of universal
newborn hearing screening are important factors to consider when evaluating
difference among these guidelines. The rationale behind disparate
recommendations that cannot be attributed to the evidence base available at the
time of guideline development is also explored in the discussion of the areas
of disagreement.
Abbreviations
used in the text and tables follow:
·
ABR, Auditory brainstem
response
·
AAP, American Academy of
Pediatrics
·
CTFPHC, Canadian Task
Force on Preventive Health Care
·
EOAE, Evoked otoacoustic
emissions
·
ICSI, Institute for
Clinical Systems Improvement
·
OAE, Otoacoustic
emissions
·
OMAR, Office of Medical
Applications of Research
·
UNHS, Universal newborn
hearing screening
·
USPSTF, United States
Preventive Services Task Force
GUIDELINE CONTENT COMPARISON
A
direct comparison of guidelines issued by USPSTF, OMAR, CTFPHC, AAP, and ICSI
for infant hearing screening are provided in Tables 1-3. The Office of Medical
Applications of Research (OMAR) convened a consensus conference to specifically
address issues surrounding early identification of hearing impairment in
infants and children. Their conclusions relate to the practice of universal
newborn hearing screening (UNHS) prior to hospital discharge following birth,
as well as to which screening tests should be used. The guidelines issued by
the United States Preventive Services Task Force (USPSTF) and the American
Academy of Pediatrics (AAP) likewise present recommendations regarding UNHS
prior to hospital discharge, as well as which screening tests should be used.
All three of these organizations provide explicit reasoning behind their
judgments. In addition, two of the guidelines (OMAR and USPSTF) provide
recommendations regarding the role of the parent and/or primary care physician
in ongoing surveillance for hearing impairment following hospital discharge. In
contrast, the Canadian Task Force on Preventive Health Care (CTFPHC) and the
Institute for Clinical Systems Improvement (ICSI) present guidelines for
specific preventive health services that should be included in periodic health
examinations. Their recommendations only briefly address hearing screening in
the context of routine health examinations. In addition, the CTFPHC presents a
brief discussion of which test should be used and why, while the ICSI guideline
does not. Neither CTFPHC nor ICSI address the issue of universal newborn
hearing screening prior to hospital discharge after birth.
In
addition to infant hearing screening, the USPSTF guideline presents
recommendations for the use of pure-tone audiometry, and screening methods for
detecting hearing loss in older individuals (i.e., written patient
questionnaires, clinical history-taking and physical examination, audiometry
with hand-held devices, and simple clinical techniques such as the whispered
voice test). AAP presents recommendations for the tracking and follow-up
elements of universal newborn hearing programs, as well as for the ongoing
evaluation of state-monitored systems.
In the
following sections, the areas of agreement and difference between the
guidelines are evaluated with respect to: 1) hearing screening in early
infancy; 2) the issue of UNHS prior to hospital discharge; 3) ongoing
surveillance in the primary care setting and through parental concern; and 4)
recommended screening methods.
Areas of Agreement
Hearing screening in early infancy
All
five guidelines are in general agreement with the policy of screening infants
for hearing loss either prior to hospital discharge (OMAR, AAP) or through
ongoing surveillance at well baby visits (ICSI, CTFPHC, USPSTF). OMAR and AAP
endorse universal newborn hearing screening, with a goal of identifying all
infants with hearing loss prior to the age of 3 months and initiating treatment
by 6 months. Because of the unique accessibility of almost all infants in the
newborn nursery (excepting those born in alternative birthing facilities such
as the home) both of these organizations recommend that screening take place
prior to hospital discharge after birth. AAP also recommends that screening be
available for all out-of-hospital births. Similarly, ICSI and CTFPHC recommend
systematic hearing evaluation within the first month of life as well as at
subsequent well-baby visits. Although these organizations do not provide
recommendations for universal newborn screening prior to hospital discharge,
they do recommend that a hearing evaluation be performed on all infants at the
first well-baby visit (within 1 month after birth – CTFPHC; within the first 2
weeks - ICSI). One notable exception regards recommendations issued by USPSTF
(see Areas of Differences). Although USPSTF recommends that clinicians
examining any infant or young child remain alert for symptoms or signs of
hearing impairment, the guideline developers recommend that only infants with
risk factors for hearing impairment be screened prior to hospital discharge
after birth.
Routine hearing screening following hospital discharge
(surveillance)
CTFPHC
and ICSI both recommend repeated examination of infants for hearing loss over
the first 2 years of life. In addition, both groups support the use of
subjective/behavioral methods as opposed to physiologic methods like EOAE and
ABR testing. USPSTF and OMAR likewise agree that clinicians examining any
infant or young child should remain alert for symptoms or signs of hearing
impairment, although neither group makes a formal recommendation regarding
which screening method is preferred for routine health examinations. AAP
recommends that physicians provide hearing screening throughout early childhood
for those infants at increased risk for hearing loss (e.g., history of trauma,
meningitis) and for those demonstrating clinical signs of possible hearing
loss.
Areas of Differences
Universal infant hearing screening prior to hospital
discharge
Recommendations
by USPSTF, OMAR and AAP differ regarding the endorsement of universal newborn
screening prior to hospital discharge. As noted above, OMAR and AAP recommend
the implementation of universal screening prior to hospital discharge after
birth in all infants based on evidence that undetected hearing impairment
during infancy and early childhood interferes with the development of speech
and verbal language skills. USPSTF on the other hand, states that there is
insufficient evidence to recommend for or against universal screening of
asymptomatic infants, noting that the cost and feasibility of universal
screening are not fully known. USPSTF does not dispute that reduced hearing
during infancy is associated with developmental delay in speech and language.
They simply state that no controlled clinical trials have yet evaluated the
efficacy of early screening in terms of long-term function and quality of life
outcomes. In addition, USPSTF state that current screening methods (ABR and
EOAE), while having reasonably high sensitivity and specificity, yield a
substantial number of false positive results as a result of the low prevalence
of hearing loss in asymptomatic infants.
USPSTF
states that recommendations for screening high-risk infants can be made on
other grounds, including the higher prevalence of hearing loss among high-risk
infants. USPSTF therefore recommends that all high-risk infants be screened for
hearing loss prior to hospital discharge and/or before the age of 3 months.
OMAR and AAP note that a policy of screening only high-risk infants will
neglect approximately 50% of infants with hearing loss.
The role of parental concern in on-going surveillance
CTFPHC,
USPSTF and OMAR all emphasize the role of parental concern in guiding more
formal hearing tests. OMAR specifically states that parental concern about
hearing should be sufficient reason to initiate a prompt formal hearing
evaluation. CTFPHC states that parental inquiry about infant hearing status
should be part of the routine health examinations. USPSTF recommends that
clinicians remain alert to parental/caregiver concern regarding hearing,
speech, language or developmental delay. Contrary to these guidelines, AAP
states that reliance on physician observation and/or parental recognition as a
sole means of identifying infants with hearing loss has not been successful in detecting
hearing loss in the first year of life.
Screening methods
There
are differences between the guidelines with respect to the screening technology
that is endorsed. OMAR and AAP agree that, although additional research is
necessary to determine which screening test is ideal, EOAE and/or ABR are
presently the screening methods of choice. AAP defers recommending a preferred
screening test, while OMAR specifically endorses the use of EOAE followed by
ABR stating that EOAE, with its high sensitivity (ability of the screening test
to identify infants with hearing loss) would rapidly and inexpensively pass the
majority of infants tested. ABR, with its relatively high specificity (ability
to pass infants that do not have a hearing loss), is recommended by OMAR as the
follow-up method for those infants that failed the EOAE test. Although there is
disagreement between USPSTF, and the other guidelines in terms of which infants
should be tested (see UNHS prior to hospital
discharge above), USPSTF agrees that a physiological test should be
used. The USPSTF guideline states that ABR testing is the most accurate method
available with sensitivity and specificity rates reported as high as 97-100%
and 86-96%, respectively. They further state that ABR testing may be useful for
all infants who meet at least one of the high-risk criteria or for those who
fail EOAE testing.
CTFPHC
and ICSI on the other hand, endorse routine screening of hearing in infants
during the first two years of life using subjective and/or behavioral assessment.
ICSI does not explicitly state which screening method they endorse, just that
screening is recommended through subjective assessment. Conversely, CTFPHC
specifically endorses the use of parental questioning and the “clap test” as
opposed to screening with EOAE or ABR. CTFPHC refers to evidence laid out in
the OMAR consensus statement in making their recommendation regarding screening
method. Specifically, they note that the OMAR consensus statement acknowledges
a high false positive rate using either ABR or EOAE testing and that much of
the evidence supporting the use of these techniques is descriptive, and that no
randomized trials have been done to support their use over and above parental
inquiries and the clap test.
Guidelines Reviewed
1.
United States Preventive
Services Task Force (USPSTF). Screening for hearing impairment. In: Guide to clinical
preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996.
393-406 [88 references]
2.
Office of Medical
Applications of Research (OMAR). Early identification of hearing impairment in infants and young
children. NIH Consens Statement 1993 Mar 1-3;11(1):1-24. The document,
"Recommendations of the NIDCD Working Group on Early Identification of
Hearing Impairment on Acceptable Protocols for Use in State-Wide Universal
Newborn Hearing Screening Programs," (Bethesda (MD): National Institute on
Deafness and Other Communication Disorders (NIDCD); 1997 Sep. 2 p.) is
considered to be a supplement to the original guideline.
3.
Canadian Task Force on
Preventive Health Care (CTFPHC). Well-baby care in the first 2 years of life. In: Canadian
guide to clinical preventive health care. Ottawa: Health Canada; 1994 Mar.
258-66 [12 references]
4.
American Academy of
Pediatrics (AAP). Newborn and infant hearing loss: detection and intervention.
Pediatrics 1999 Feb;103(2):527-30 [30 references]
5.
Institute for Clinical
Systems Improvement (ICSI). Preventive services for children. Bloomington (MN): Institute
for Clinical Systems Improvement; 2000 Mar. 36 p. [19 references]
TABLE 1: OVERVIEW OF GUIDELINES FOR INFANT
HEARING SCREENING |
|
|
OBJECTIVE
AND SCOPE |
USPSTF |
|
OMAR |
To address the
following:
|
CTFPHC |
|
AAP |
|
ICSI |
|
|
TARGET
POPULATION |
USPSTF |
|
OMAR |
Newborn infants and
young children |
CTFPHC |
Infants (birth to 2
years) |
AAP |
Newborn infants |
ICSI |
Low-risk, asymptomatic
individuals from birth to 18 years of age |
|
INTENDED
USERS |
USPSTF |
Physicians, nurses, nurse practitioners, physician
assistants, allied health care practitioners, students |
OMAR |
Physicians, speech-language pathologists, nurses, nurse
practitioners, physician assistants, allied health care practitioners, health
plans |
CTFPHC |
Physicians, nurses, nurse practitioners, physician
assistants, allied health care practitioners, students |
AAP |
Physicians, audiologist, speech and language therapists,
nurses, nurse practitioners, physician assistants, allied health care
practitioners, health plans, other |
ICSI |
Physicians, nurses, nurse practitioners, physician
assistants, allied health care practitioners |
|
INTERVENTIONS
AND PRACTICES CONSIDERED |
USPSTF |
Screening:
Screening Methods:
Other:
|
OMAR |
Screening:
Screening Methods:
Education:
|
CTFPHC |
Screening:
Screening Methods:
Other:
|
AAP |
Screening:
Screening Methods:
Other:
|
ICSI |
Screening:
Other:
|
TABLE 2: SCREENING RECOMMENDATIONS |
|
Guideline |
Hearing
screening prior to hospital discharge after birth? |
USPSTF |
|
OMAR |
|
CTFPHC |
|
AAP |
|
ICSI |
|
Guideline |
Routine
hearing screening following hospital discharge (surveillance) |
USPSTF |
|
OMAR |
|
CTFPHC |
|
AAP |
|
ICSI |
|
Guideline |
What
type of screening test should be used? |
USPSTF |
|
OMAR |
|
CTFPHC |
|
AAP |
|
ICSI |
|
Guideline |
Rating
Scheme |
USPSTF |
Recommendation
Grade:
|
OMAR |
Not stated |
CTFPHC |
Recommendation
Grade:
Level of Evidence: I - Evidence from at least 1 properly randomized controlled trial
(RCT). |
AAP |
Not stated |
ICSI |
Rating
Scheme for the Strength of the Evidence
Class B:
Class C:
Class D:
Class R:
Class X:
|
TABLE 3: BENEFITS AND HARMS |
||
Guideline |
POTENTIAL
BENEFITS |
POTENTIAL
HARMS |
USPSTF |
|
|
OMAR |
|
|
CTFPHC |
|
|
AAP |
|
|
ICSI |
|
|
Updates in Progress: A third USPSTF was appointed in September 1998 by the Agency for
Health Care Policy and Research (now known as the Agency for Healthcare
Research and Quality [AHRQ]). Individual USPSTF recommendations are currently
being updated, with plans that all recommendations will be reviewed and updated
by 2002. CTFPHC reviewed the evidence for infant hearing screening in 1994 and
endorsed the recommendations again in 1998. A review of the evidence for
screening of newborn infants specifically is currently in progress. The ICSI
guideline will be updated June-July 2001 with Committee approval expected in
September 2001.
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.