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
(1996)
  • To provide recommendations for screening for hearing impairment

OMAR
(1993, updated 1997)

To address the following:

  • The advantages of early identification of hearing impairment and the consequences of late identification of hearing impairment
  • Which children should be screened for hearing impairment and when
  • The advantages and disadvantages of current screening methods
  • Which model for hearing screening and follow-up is preferred
  • Future directions for research in diagnosis and management of hearing impairment in infants and young children

CTFPHC
(1994, reviewed 1998)
  • To make recommendations about well-baby care for Canadian infants during their first 2 years of life, updating a report published in 1990

AAP
(1999)
  • To endorse the implementation of universal newborn hearing screening
  • To review the primary objectives, important components, and recommended screening parameters that characterize an effective universal newborn hearing screening program

ICSI
(2000)
  • To clearly identify those preventive services which are essential to provide to all low risk or asymptomatic patients on the basis of either good or fair evidence for inclusion in a periodic health evaluation
  • To identify those services that should not be included in light of similarly strong evidence

 

TARGET POPULATION

USPSTF
(1996)
  • Asymptomatic and high-risk infants
  • Asymptomatic children and adolescents
  • Working-age adults, including those exposed to excessive noise levels
  • Older adults

OMAR
(1993, updated 1997)

Newborn infants and young children

CTFPHC
(1994, reviewed 1998)

Infants (birth to 2 years)

AAP
(1999)

Newborn infants

ICSI
(2000)

Low-risk, asymptomatic individuals from birth to 18 years of age

 

INTENDED USERS

USPSTF
(1996)

Physicians, nurses, nurse practitioners, physician assistants, allied health care practitioners, students

OMAR
(1993, updated 1997)

Physicians, speech-language pathologists, nurses, nurse practitioners, physician assistants, allied health care practitioners, health plans

CTFPHC
(1994, reviewed 1998)

Physicians, nurses, nurse practitioners, physician assistants, allied health care practitioners, students

AAP
(1999)

Physicians, audiologist, speech and language therapists, nurses, nurse practitioners, physician assistants, allied health care practitioners, health plans, other

ICSI
(2000)

Physicians, nurses, nurse practitioners, physician assistants, allied health care practitioners

 

INTERVENTIONS AND PRACTICES CONSIDERED

USPSTF
(1996)

Screening:

  • Hearing screening of high-risk infants
  • Ongoing surveillance via well baby visits and parental observation

Screening Methods:

  • ABR
  • EOAE
  • High-risk registrar

Other:

  • Pure-tone audiometry for screening adults and cooperative children
  • Screening methods for detecting hearing loss among older persons

OMAR
(1993, updated 1997)

Screening:

  • Universal screening for hearing loss among infants before 3 months of age
  • Ongoing surveillance for hearing loss throughout infancy and early childhood

Screening Methods:

  • ABR
  • EOAE

Education:

  • Education of primary caregivers and primary health care providers on early signs of hearing impairment

CTFPHC
(1994, reviewed 1998)

Screening:

  • Routine hearing screening as part of the periodic health examination in the first 2 years of life

Screening Methods:

  • Parental enquiries and/or the clap test
  • ABR and EOAE are considered but not recommended

Other:

  • Frequency of well-baby care visits
  • Parental counseling on safety, nutrition and behavioral problems
  • Identification and treatment of physical, developmental and parenting problems

AAP
(1999)

Screening:

  • Universal screening for hearing loss among all newborn infants

Screening Methods:

  • ABR
  • EOAE

Other:

  • Tracking and follow-up elements of a UNHS program
  • Identification and intervention practices
  • On-going evaluation of the UNHS program by state monitored systems

ICSI
(2000)

Screening:

  • Routine hearing screening as part of the periodic health examination in the first 2 years of life

Other:

  • Frequency of well-baby care visits
  • Additional screening maneuvers
  • Counseling and education
  • Immunization practices

 

TABLE 2: SCREENING RECOMMENDATIONS

Guideline

Hearing screening prior to hospital discharge after birth?

USPSTF
(1996)
  • There is insufficient evidence to recommend for or against routine screening of asymptomatic neonates for hearing impairment using EOAE or ABR. (C-Recommendation)
  • Recommendations to screen high-risk infants may be made on other grounds, including the relatively high prevalence of hearing impairment, parental anxiety or concern, and the potentially beneficial effect on language development from early treatment of infants with moderate or severe hearing loss. For many high-risk conditions, hearing testing is commonly considered to be part of diagnostic evaluation and management.
  • Risk factors for congenital or perinatally acquired hearing loss include: family history of hereditary childhood sensorineural hearing loss; congenital perinatal infection with herpes, syphilis, rubella, cytomegalovirus, or toxoplasmosis; malformations involving the head or neck (e.g., dysmorphic and syndromal abnormalities, cleft palate, abnormal pinna); birth weight below 1,500 g; bacterial meningitis; hyperbilirubinemia requiring exchange transfusion; severe perinatal asphyxia (Apgar scores of 0-4 at 1 minute or 0-6 at 5 minutes, absence of spontaneous respirations for 10 minutes, or hypotonia at 2 hours of age); ototoxic medications; and findings associated with a syndrome known to include hearing loss.
  • High-risk infants should ideally be screened prior to leaving the hospital after birth, but those not tested at birth should be screened before age 3 months with the goal being to initiate rehabilitation by age 6 months as clinically indicated.

OMAR
(1993, updated 1997)
  • The panel recommends that all infants admitted to the neonatal intensive care unit as well as high-risk infants from the well-baby nursery (i.e., craniofacial anomalies, family history of hearing loss, and diagnosis of intrauterine infection) be screened for hearing loss prior to discharge.
  • In addition, the panel recommends that universal screening be implemented for all infants within the first 3 months of life. Because of the unique accessibility of almost all infants in the newborn nursery, the consensus panel recommends screening of all newborns, both high and low risk, for hearing impairment prior to hospital discharge.
  • To improve the accuracy and efficiency of the test, screening should take place as close to discharge as possible.
  • All babies that who fail the initial screen should be rescreened by ABR methodology. Babies who fail the ABR screen should be referred for diagnostic evaluation to verify the existence and to determine the type and severity of hearing impairment, and to initiate a remediation program for the child and family.
  • Treatment should be initiated by 6 months of age.

CTFPHC
(1994, reviewed 1998)
  • Not addressed

AAP
(1999)
  • The task force on Newborn and infant hearing endorses the implementation of universal newborn hearing screening. Newborn screening has as its goal that 100% of the target population, consisting of all newborns, will be tested in both ears prior to the age of 3 months, with appropriate intervention prior to the age of 6 months. Screening should be conducted before discharge from the hospital whenever possible.

ICSI
(2000)
  • Not addressed

Guideline

Routine hearing screening following hospital discharge (surveillance)

USPSTF
(1996)
  • Clinicians examining any infant or young child should remain alert for symptoms or signs of hearing impairment, including parent/caregiver concern regarding hearing, speech, language, or developmental delay.

OMAR
(1993, updated 1997)
  • Because 20-30 percent of children who have hearing impairment develop hearing loss during early childhood (subsequent to hospital discharge after birth), an ever-vigilant pluralistic approach must be taken to screen and identify hearing loss in young children.
  • The first approach must include eliciting and acknowledging parental concern. Parental concern about hearing should be sufficient reason to initiate prompt formal hearing evaluation.
  • Another necessary approach includes ongoing evaluation of speech and language development at routine child health supervision visits using formal assessment tools.
  • Education of primary caregivers and primary health care providers on early signs of hearing impairment is essential.

CTFPHC
(1994, reviewed 1998)
  • Good evidence exists to include repeated examinations of hearing in the periodic health examination of well babies, especially in the first year [Grade A, Evidence level II-2, III].

AAP
(1999)
  • Physicians should provide recommended hearing screening, not only during early infancy but also through early childhood for those children at risk for hearing loss (e.g., history of trauma, meningitis) and for those demonstrating clinical signs of possible hearing loss.

ICSI
(2000)
  • Hearing testing is recommended for well-baby visits (Schedule of visits: first 2 weeks, 2, 4, 6-9, 15 months). Evidence supporting this conclusion is of class: R

Guideline

What type of screening test should be used?

USPSTF
(1996)
  • ABR testing may be useful for all infants who meet at least one of the high-risk criteria or for those who fail EAOE testing. (See Hearing screening prior to hospital discharge after birth? above for high-risk criteria).

OMAR
(1993, updated 1997)
  • The preferred model for screening should begin with an EOAE test and should be followed by an ABR test for all infants who fail the EOAE test.
  • Behavioral testing (such as visual reinforcement audiometry or conditioned orienting response), usually at 6 months of age or later, may be used to detect hearing impairment in almost all infants prior to the acquisition of speech and language.

CTFPHC
(1994, reviewed 1998)
  • Parental questioning and the clap test.
  • Although repeated examination of hearing is recommended, there is insufficient evidence at this time to recommend that routine use of ABR or EOAE for hearing screening of healthy babies should replace regular assessment of hearing during well-baby visits using parental questioning and the clap test.

AAP
(1999)
  • The methodology should detect, at a minimum, all infants with significant bilateral hearing impairment, i.e., those with hearing loss > 35-decibel in the better ear.
  • The methodology used in screening should have a false-positive rate, i.e., 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%.
  • The methodology used in screening ideally should have a false-negative rate (i.e., the proportion of infants with significant hearing loss missed by the screening program), of zero.
  • 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 EOAE and ABR, either alone or in combination. Both methodologies are noninvasive, quick (< 5 minutes), and easy to perform, although each assesses hearing differently.
  • 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 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. 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.

ICSI
(2000)
  • Hearing testing is recommended through subjective assessment. Evidence supporting this conclusion is of class: R

Guideline

Rating Scheme

USPSTF
(1996)

Recommendation Grade:

  1. There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
  2. There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
  3. There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.
  4. There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
  5. There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

OMAR
(1993, updated 1997)

Not stated

CTFPHC
(1994, reviewed 1998)

Recommendation Grade:

  1. Good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
  2. Fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
  3. Poor evidence regarding inclusion or exclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.
  4. Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a periodic health examination.
  5. Good evidence to support the recommendation that the condition be specifically excluded from consideration in a periodic health examination.

Level of Evidence:

I - Evidence from at least 1 properly randomized controlled trial (RCT).
II-1 - Evidence from well-designed controlled trials without randomization.
II-2 - Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3 - Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III - Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

AAP
(1999)

Not stated

ICSI
(2000)

Rating Scheme for the Strength of the Evidence
Evidence Grading System: Classes of Research Reports:

  1. Primary Reports of New Data Collection:
    Class A:
    • Randomized, controlled trial

Class B:

    • Cohort study

Class C:

    • Non-randomized trial with concurrent or historical controls
    • Case-control study
    • Study of sensitivity and specificity of a diagnostic test
    • Population-based descriptive study

Class D:

    • Cross-sectional study
    • Case series
    • Case reports
  1. Reports that Synthesize or Reflect upon Collections of Primary Reports
    Class M:
    • Meta-analysis
    • Decision analysis
    • Cost-benefit analysis
    • Cost-effectiveness study

Class R:

    • Review article
    • Consensus statement
    • Consensus report

Class X:

    • Medical opinion

 

TABLE 3: BENEFITS AND HARMS

Guideline

POTENTIAL BENEFITS

POTENTIAL HARMS

USPSTF
(1996)
  • In high-risk infants, earlier detection and treatment of hearing impairment may prevent developmental delay in speech and language function.
  • False Positives: Although screening mechanisms have reasonable sensitivity and specificity, a substantial number of infants will be misclassified because the prevalence of hearing impairment in asymptomatic neonates is low.

OMAR
(1993, updated 1997)
  • In general, early identification and intervention of hearing impairment in infants will minimize and/or prevent deficits in speech and language acquisition, academic achievement, and social/emotional development that might otherwise occur in infants with unidentified hearing loss.
  • The benefits to be gained from early intervention may vary, depending on the severity and type of hearing impairment. Children with sensorineural hearing loss who receive early amplification, when indicated, and a comprehensive rehabilitation program may show improved speech and language skills, school achievement, self-esteem, and psychosocial adaptation when compared to hearing-impaired children who do not receive amplification until 2 to 3 years of age.
  • The addition of screening in the well-baby nursery as a part of well-baby care will increase cost.
  • Relative to EOAE, ABR screening and follow-up is expensive and requires trained personnel.
  • High false positive rates associated with both EOAE and ABR result in over-referral of infants with normal hearing and undue parental anxiety.
  • Disadvantages associated with behavioral screening of infants > 6 months of age include the following: (1) requires skilled personnel and is time-consuming; (2) evaluation of older infants requires reasonable access to a testing facility; (3) testing is difficult in developmentally delayed infants who are the highest risk; and, (4) some infants would not be treated until after 1 year of life because of a lack of lead time to implement intervention.

CTFPHC
(1994, reviewed 1998)
  • The early detection of certain physical problems, such as deafness, can lead to effective interventions that prevent important physical and emotional difficulties. For instance, if profound hearing loss is not identified within the first year of life, the likelihood that the child will have intelligible speech and attain educational standards commensurate with intellectual ability will be greatly reduced.
  • A cohort study showed that children with profound hearing loss (at least 70 dB in the speech frequencies) had better sentence construction if hearing aids and training were introduced before 3 years of age.
  • None stated

AAP
(1999)
  • Screening by high-risk registry alone (e.g., family history of deafness) can only identify ~50% of newborns with significant congenital hearing loss. 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.
  • 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.
  • False Positives: A proportion of infants without hearing loss will be labeled incorrectly by the screening process as having significant hearing loss. These infants will require additional testing. The goals of universal screening programs include maintaining this false-positive rate at < 3% and the referral rate for formal audiologic testing after screening at < 4%.

ICSI
(2000)
  • No benefits were discussed relating to hearing screening for infants.
  • None stated

 

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.