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4.3.4 Osseointegrated Auditory Implant
ab
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
OAI is another form of hearing technology available to patients
who derive benefit from external bone conduction hearing aids.
Indications within the pediatric population include the inability
to benefit from or utilize air conduction hearing aids and being
at least 5 years of age with a skull thickness of at least 3 mm.
Patients with bilateral mixed or CHL and those with unilateral
profound SNHL are eligible for placement of OAI. Compared
to external bone conduction hearing aids, OAIs have better
high-frequency gain and less distortion and are notably more
secure.71 The OAI consists of an external microphone/sound
processor that attaches to an osseointegrated screw located in
the skull. Sound presented to the external processor is conveyed
as vibration through the osseointegrated implant into the bone
and ultimately transmitted to the structures of the inner ear by
bone conduction. The overall success rate of OAI is reported at
over 90%.
screw, surgical ap infection, and exceedingly rare intracranial
complications. Nonosseointegration may be as high as 40% in
children under 5 years old and lower than 8% in 5 to 10-year-olds,
demonstrating the need to delay implantation until the appropriate skull development has occurred (F
72
Complications include nonosseointegration of the
ig. 4 .10).
73
4 Medical Management of Hearing Loss in Children
Fig. 4.10 OAI. (Used with permission from Cochlear Americas and
Madell J, Flexer C. Pediatric Audiology, 2nd ed. New York, NY: Thieme
Publishers; 2014.)
4.3.5 Ossicular Chain Reconstruction
OCR is the treatment for trauma, infection, or congenital malformation that results in malfunction of the incus, malleus, or
stapes. The goal of the procedure is to reestablish proper function
of the ossicles. This is achieved via repositioning of the native
ossicles or insertion of prosthetic replacements. Because there
are a variety of malformations of the auditory ossicles, OCRs can
be either total or partial. As with all surgery of the middle ear,
it is important that middle ear infection be ruled out or treated
prior to intervention. The success of OCR is dependent on mul-
tiple variables, including absence of middle ear inammation,
adequate eustachian tube function, and presence of ossicles at
time of surgery.74 Improvement in air-bone gaps occurs in 50 to
75% of children who undergo OCR.
75,76
Complications from OCR
include prosthesis extrusion, cholesteatoma, and tympanic
membrane perforation, all of which are amenable to further
surgical intervention (Fig . 4 .11).
77
4.3.6 Stapedotomy
Stapedotomy is the intervention of choice when the stapes
either forms without proper mobility, thus limiting its ability to
transmit sound to the inner ear, or has diminished mobility as
a result of fixation by otosclerosis or tympanosclerosis. In both
circumstances the goal of the procedure is to restore mobility
to the stapes via either manipulation of the stapes or insertion
of a prosthesis. Improvements in air-bone gap are more notable
in patients after stapedotomy regardless of the etiology, yet the
degree of improvement depends heavily on surgical skill and
on the etiology, with otosclerosis faring better than congenital
stapes footplate fixation.
78,79
Fig. 4.11 OCR. (a) Partial ossicular replacement prosthesis (PORP). (b)
Total ossicular replacement prosthesis (TORP). (Used with permission
from Behrbohm H, Kaschke O, Nawka T, Swift A. Ear, Nose and Throat
Diseases, 3rd ed. New York, NY: Thieme Publishers; 2010.)
4.3.7 Cochlear Implantation
Since the first experiments involving implantation of electrodes
in the cochlea, beginning in 1961, CIs have undergone steady
development. Single-channel devices showed slight success
in improving speech recognition, and the first multichannel
implants were patented and commercialized in the late 1970s.80
In the mid 1980s the US FDA approved the first multichannel
devices, and in 1990 these devices were approved for implantation in children 2 years and older. CIs remain an active area of
interest to researchers even as several hundred thousand devices
have been implanted worldwide (Fig. 4 .12).
The CI device comprises an external and an internal portion. The
external portion contains a microphone and speech processor that
rests on the auricle or behind it. This external device is connected
to a transmitting coil that is bound to the scalp via subcutaneous
magnet to the internal receiver. This receiver relays transmitted
signals into the cochlea via individual electrodes, where it directly
stimulates the cochlear nerve, resulting in hearing.
There are several FDA criteria for CI candidacy. Audiometric
criteria include > 90 dB HL pure tone average bilaterally in children 12 to 24 months old and > 70 dB HL pure tone average in
children 2 years or older. In preverbal children, a trial of hearing
aids must prove unfruitful based on a lack of sucient auditory
81
51
I Hearing Loss: Essential Information
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
skill development. Criteria for CI continue to expand, with children with severe hearing loss being routinely implanted at many
centers worldwide. Implantation for children less than 12 months
is becoming more frequent as well (see Chapter 22).
Any middle ear infection should be adequately treated prior
to intervention, and the recipient should receive vaccinations
against common bacteria that cause meningitis. It is also important that patients and families be motivated and have realistic
expectations prior to CI, as results vary by individual, and it takes
significant eort to develop communication after implantation
to achieve favorable results. Those who should not receive a CI
include those who simply do not desire auditory input and those
without a cochlea (Michel malformation). In late-presenting (i.e.,
older than 8 years), prelingually deaf children with no previous
spoken language, it is important that patient and family members
understand that CI may facilitate sound awareness but most likely
will not result in development of oral communication.
Complications of CI include surgical ap issues, vestibular
hypofunction, facial palsy, device displacement, meningitis,
chronic otitis media, device failure, and electrode extrusion. Minor
complications occur in 6 to 10% of pediatric patients, while major
complications occur in 1 to 5%, making cochlear implantation a
safe surgical option for HL.
implants is a moving target depending on manufacturer and
model but currently is under 4%, with as many as 8% of patients
ultimately requiring revision surgery for some reason.
As the technology behind CIs has improved, their clinical
indications have expanded. One promising use is combining CI
with hearing preservation instead of waiting to implant until an
individual has severe or profound HL at all frequencies. Research
has shown improved speech intelligibility and preservation of
low-frequency hearing in those who had CI with hearing preservation.86 This benefit is achieved by implanting patients who have
retained a degree of low-frequency hearing while strategically
using the CI’s ability to stimulate high-frequency hearing to provide a more complete representation of sound. Using CIs in this
manner also allows for further augmentation of low-frequency
hearing via ipsilateral hearing aid usage. This method of hearing
augmentation is referred to as electroacoustic stimulation (EAS)
or hybrid hearing. Further benefits of concurrent acoustic (hearing
aid) and electrical (CI) stimulation include better pitch discrimination, song recognition, interval perception, and improvement in
in this way does aid in the preservation of hearing in many individuals, it does not completely inhibit the eventual deterioration
of hearing. Additionally, data exploring the outcomes of using CIs
in this manner indicate that outcomes are still extremely variable,
with a sizable minority of the patients experiencing complete HL
or a precipitous drop in hearing soon after implantation or in a
delayed fashion.91 Current studies are ongoing to identify the best
available technology, surgical technique, and medical treatment
to improve outcomes in hearing preservation CI surgery.
82,83,84
The device failure rate of cochlear
87,88,89,90
It is notable that although utilizing CIs
85
Pearl
The indications for CI are constantly expanding as more patients
with diverse etiologies of HL benet from CI placement.
Children who receive CIs early in life and receive auditory-based
speech-language therapy typically develop oral communication
and become primary oral communicators, enabling them to
engage in mainstream social and educational environments.92
Studies have shown that those implanted earlier, with greater
family support, in environments where oral communication is
emphasized, and with the absence of cognitive diagnoses fare
better than those without these characteristics.93 With such
demonstrated benefits from CIs, their use is being investigated
in populations that were previously excluded. These include
children with unilateral deafness and children with less severe
HL than currently recommended for CI.
appears to reinforce the benefits of CI in children, and as technology advances, continued improvement is expected.
81,94
Ongoing research
Pearl
Children who receive CI early in life are capable of developing
oral communication and engaging in mainstream social and
educational environments.
4.4 Conclusion
Pediatric HL is a multifaceted disability that has important
implications for normal cognitive development of children
during their pediatric years and into adult life. There are both
nonmedical and medical therapies that help children address
this issue. Medicine’s role in the management of pediatric HL is to
use history, physical exam, and testing to identify the most likely
etiology and then develop a treatment plan to address the issue.
There are multiple treatment options for pediatric patients, and
choices among them are dictated by the etiology and the goals
of the patient and their family. Current research continues to
expand treatments that will continue to improve the quality of
life of patients with pediatric HL well into the future.
Discussion Questions
1. How does the physician’s exam complement audiology
testing?
2. What is the risk of continued middle ear eusion in children,
and what is its treatment?
3. What is a cholesteatoma, and what are its potential
complications?
4. What is the most common nongenetic cause of SNHL in
developed nations? Why is it important to test infants for this
etiology shortly after birth?
5. What are three etiologies for hearing loss that can be identi-
ed only via CT or MRI?
6. What type of patient is most likely to derive the greatest
benet from a cochlear implant?
52
Fig. 4.12 Cochlear implant placement. The acoustic signal is received
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
by a mircrophone (1) worn behind the ear and is processed by an
extrenal speech processor (2). An electronic receiver (3) is implanted
into the temporal bone under the skin. It is connected to an electrode
array (4) inserted into the cochlea (5). The electrodes directly stimulate
the vestibulocochlear nerve (6). (Used with permission from Behrbohm
H, Kaschke O, Nawka T, Swift A. Ear, Nose and Throat Diseases, 3rd ed.
New York, NY: Thieme Publishers, 2010.)
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implantation in children and their management. Int J Pediatr Otorhinolaryngol
2014;78(7):1040–1044
ar implant complications in 403 patients: comparative study of adults and
c
hildren and review of the literature. Eur Ann Otorhinolaryngol Head Neck Dis
2014;131(3):177–182
failure in cochlear implant surgery: a 30-year experience. Laryngoscope
2014;124(10):2393–2399
implant: a review. Adv Otorhinolaryngol 2010;67:125–134
acoustic stimulation users as assessed by the Mu.S.I.C. test. Adv Otorhinolaryngol
2010;67:70–80
cochlear implants and residual hearing. Audiol Neurootol 2006;11(Suppl 1):
12–15
pitch perception, melody recognition, and speech reception in noise. Ear Hear
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ulation of the auditory system: results of a multi-centre investigation. Acta
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hearing loss in hearing preservation cochlear implant surgery. Otol Neurotol
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velopment in profoundly deaf children with cochlear implants. Psychol Sci
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copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
5 Newborn Hearing Screening
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Karl R. White and Karen Muñoz
5 Newborn Hearing Screening
Summary
This chapter describes how the percentage of babies in the United
States who received newborn hearing screening grew from 3 per-
cent in 1988 to 98 percent today. Not only has the number of babies
screened for hearing loss increased dramatically, but newborn
hearing screening programs have provided the foundation for earlier diagnosis and better educational outcomes for children who
are deaf or hard of hearing. These improvements did not happen
all at once. Various factors that contributed to making newborn
hearing screening programs more eective are discussed. The
most important factors have included policy initiatives, federal
funding programs, promotion of best practices by various professional and advocacy groups, technological advances, and legislative actions by almost all states. The features that are essential for
establishing and operating successful newborn hearing screening
programs are also summarized. Practical suggestions are given
for how to create stakeholder support, selecting equipment and
newborn hearing screening protocols, dealing with procedural
issues, communicating with stakeholders, training and supervis-
ing screeners, and eciently and appropriately managing data
and patient information. Equipment, protocols, and procedures
used in successful newborn hearing screening programs vary
widely depending on the circumstances and preferences of those
responsible for the program; there is no one best approach. It is
clear that the best newborn hearing screening programs are based
on well-defined goals, clearly specified roles and responsibilities
for sta, and regular monitoring and reporting of results.
Keywords
newborn, hearing screening, hearing loss, legislation, technological advances, screening equipment, data management
Key Points
Virtually all newborns in the United States are screened for
•
hearing loss before they are a month old.
Because of federally funded initiatives, research and technology
•
advances, and legislative mandates in 43 states, newborn hearing
screening has become the standard of care in the United States.
Equipment, protocols, and procedures used in successful
•
newborn hearing screening programs vary widely depending
on the circumstances and preferences of those responsible
for the program; there is no one best approach.
To be eective, newborn hearing screening programs need
•
well-dened goals, clearly specied roles and responsibilities
for sta, and regular monitoring and reporting of results.
The most successful programs are excellent at involving and
•
communicating with a range of stakeholders (e.g., hospital
sta and administrators, primary health care providers, parents, and hearing health professionals).
5.1 Factors Contributing to the
Expansion of Newborn Hearing
Screening Programs
During the past 35 years the percentage of newborns being
screened for hearing loss has increased from 3 to 98% (Fig. 5.1).1
What has contributed to such a dramatic increase, and what can
we learn from these experiences that will enable us to continue
to improve programs for identifying and serving infants and
young children who are deaf or hard of hearing? As will be
clear in this chapter, the equipment, protocols, and procedures
used in successful newborn hearing screening programs vary
widely depending on the circumstances and preferences of those
responsible for the program; there is no one best approach. The
most successful programs, though, are carefully administered
and are excellent at involving and communicating with a range
of stakeholders including hospital sta and administrators,
primary health care providers, parents, and hearing health
professionals.
Important factors that have contributed the growth of newborn
hearing screening include (1) policy initiatives by government,
professional associations, and advocacy groups; (2) financial
assistance from the federal government; (3) improvements in
technology; (4) legislative initiatives; and (5) lessons learned from
successful programs.
5.1.1 Policy Initiatives
The federal government has been advocating for earlier identification of children’s hearing loss for over 50 years.2 Based on the
pioneering work of Marion Downs,3 the Joint Committee on Infant
Hearing (JCIH)4 was established in 1969 by a group of professional
and advocacy associations (the American Speech-LanguageHearing Association [ASHA], American Academy of Pediatrics
Fi g . 5.1 Percentage of newborns screened in the United States for
hearing loss from 1988 through 2014.
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copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
[AAP], and the American Academy of Otolaryngology—Head and
Neck Surgery, among others). The purpose of the JCIH was to
advocate for earlier identification and better treatment of infants
and young children who are deaf or hard of hearing. In 1984 the
congressionally mandated Commission on Education of the Deaf
recommended that the federal government should “assist states in
implementing improved screening procedures for each live birth.”
Progress was slow, however, until the late 1980s, when new
hearing screening technologies became available, leading to the
inclusion of an objective in the Healthy People 2000 report6 to
“reduce the average age at which children with significant hearing
[loss] are identified to no more than 12 months.” Although the
objective was similar to what had been advocated for several
decades, its inclusion in Healthy People 2000 required that progress
toward the achievement of this objective be tracked and reported
at regular intervals. In March 1993, the National Institutes of Health
(NIH) convened a Consensus Development Panel7 to review the
existing evidence on early identification of hearing loss and make
recommendations to improve practice. The panel recommended
“screening of all newborns . . . for hearing [loss] prior to discharge.”
Many people expected rapid implementation of universal
newborn hearing screening programs as a result of the NIH
recommendation. Others pointed out, however, that the research
evidence and experiences for such widespread implementation
were lacking. For example, one widely cited article in the agship journal of the AAP8 concluded that “the Consensus Panel’s
recommendation of universal infant screening falls short of being
justified on grounds of practicability, eectiveness, cost, and
harm-benefit ratio.” Two years later, the prestigious United States
Preventive Services Task Force (USPSTF)9 noted that “congenital
hearing loss is a serious health problem associated with develop-
mental delay in speech and language function” but concluded that
“there is little evidence to support the use of routine, universal
screening for all neonates.”
5.1.2 Federal Funding and Endorsements
by Professional and Advocacy
Groups
As the pros and cons of newborn hearing screening were being
debated, the federal government funded a number of initiatives
focused on reducing the age at which congenital hearing loss
was identified. One of the best known was the Rhode Island
Hearing Assessment Project,10 but there were many others.
By the mid-1990s the percentage of newborns being screened for
hearing loss had increased dramatically (from fewer than 3% in
1993 to 15% in 1996 to 22% in 1998; Fig. 5.1). By 1998 dozens of
large-scale universal newborn hearing screening programs had
become operational in various states.14 These projects provided
the data and the experience to support the recommendation
made by the NIH Consensus Development Panel in 1993.
As the feasibility and eectiveness of hospital-based hearing
screening became better recognized, other government, professional, and advocacy organizations added their endorsements.
For example, in 1999 the AAP “[endorsed] the goal of universal
detection of hearing loss in infants before 3 months of age . . .
[which] requires universal screening of all infants.”15 Other
organizations, including the ASHA, the American Academy of
Audiology, March of Dimes, the National Association of the Deaf,
11,12,13
7
and the American College of Medical Genetics,16 joined the call for
universal newborn hearing screening. By the end of 2001, every
state had established an early hearing detection and intervention
(EHDI) program, which was responsible for setting up newborn
hearing screening programs and linking babies referred from
those programs to diagnostic, early intervention, family support,
5
and other health care services. In 2008 the USPSTF revised their
earlier statement about newborn hearing screening and con-
cluded, “There is good evidence that newborn hearing screening
testing is highly accurate and leads to earlier identification and
treatment of infants with hearing loss. . . . Good-quality evidence
shows that early detection improves language outcomes. . . . All
infants should have hearing screening before 1 month of age.”
5.1.3 Technological Advances
The growth of newborn hearing screening programs was directly
linked to the technological advances in hearing screening
equipment that occurred during the late 1980s and early 1990s.
Without the improvements in automated auditory brainstem
response (AABR)18 and otoacoustic emissions (OAE) testing,
all of the policy initiatives, federally funded projects, and clinical
screening programs that combined to demonstrate the practicality and value of newborn hearing screening programs would
never have happened.
5.1.4 Legislation Related to Newborn
Hearing Screening
As newborn hearing screening programs expanded, legislative
action in many states increased the probability that these programs would become an integral part of the public health system.
The first legislation related to newborn hearing screening was
passed in Hawaii in 1990. Spurred on by the demonstrated suc-
cess of newborn hearing screening programs, 43 states and the
District of Columbia now have statutes or regulations requiring
newborn hearing screening.21 The increase in legislative activity
was probably inuenced by the publication in 1998 of major articles about the feasibility and benefits of implementing universal
newborn hearing screening programs.
Pearl
Many states were screening most of their newborns before passing legislation. Even though legislation is not essential to have all
babies screened, it is often helpful in rening and strengthening
the screening program and linking screening results to other
services.
12,13,22,23
5.2 Establishing and Operating
Successful Newborn Hearing
Screening Programs
As a result of work done by JCIH4 and the Centers for Disease
Control and Prevention (CDC),24 most people stopped using
17
19,2 0
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Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
the phrase “universal newborn hearing screening” and began
referring to “early hearing detection and intervention” (EHDI)
programs. The change in how these programs are described
is important, because it emphasizes that to identify and serve
infants and young children who are deaf or hard of hearing, successful screening programs must be coupled with timely diagnosis; appropriate medical, audiologic, and educational services;
coordination with the child’s primary health care provider (often
referred to as the child’s medical home25); and tracking and data
management systems. (Other chapters in this book describe
these important aspects of the EHDI system in more detail.)
In the years since the recommendation by NIH7 that all
newborns be screened for hearing loss before being discharged
from the hospital, the techniques, procedures, equipment, and
support systems for newborn hearing screening have continued
to evolve.26 The goal of screening all newborns for hearing loss,
which many thought was completely unrealistic in 1993, has been
largely attained. The remainder of this chapter summarizes some
of the most important considerations and lessons learned about
operating a successful newborn hearing screening program.
5.2.1 Creating Stakeholder Support
A successful newborn hearing screening program requires support from many stakeholders, including hospital administrators,
primary health care providers, nurses, and parents. All stakeholders should know that the endorsement of universal newborn
hearing screening by so many professional groups, coupled with
the existence of so many successful programs throughout the
country, and the ready availability of relatively inexpensive
equipment, means that newborn hearing screening has become
the de facto “standard of care.”27 Hospitals run a significant
liability risk if they do not screen all newborns for hearing loss.
Physicians, nurse practitioners, and physician assistants who
care for babies need to understand why newborn hearing screening is important and how the process is supposed to work. Ideally,
every newborn should have a health care provider who is familiar
with the baby’s circumstances and is responsible for ensuring that
the baby receives consistent and appropriate health care. Often
referred to as the baby’s medical home,25 the baby’s primary
health care provider is the key to an eective EHDI program.
Because the baby’s primary health care provider is responsible for
the total health care of the baby, he or she needs to be assured that
newborn hearing screening will not interfere with or complicate
other health care activities.
If the nursing sta in the newborn nursery is not convinced that
newborn hearing screening should be happening, it will be almost
impossible to have a successful program. If the nurses want newborn hearing screening, they can often convince the health care
sta and administrators to give it a try. In fact, some of the earliest
successful hospital-based newborn hearing screening programs
were started and largely operated by nursing sta.
5.2.2 Selecting Equipment and Protocols
for the Hospital
One of the first decisions in setting up a newborn hearing
screening program is deciding what equipment to use and what
type of basic screening protocols to follow. The good news is
that many options have been successfully implemented. The bad
news is that because there are so many options, some people
unnecessarily delay the implementation of a newborn hearing
screening program while they are considering the pros and cons
of dierent options.
The best approach is to talk to people who have tried some
of the most frequently used options; devote some brief, but
intensive, study time to what type of equipment and protocol is
best for the situation; and then make a choice and move ahead.
Waiting to identify the “perfect” solution for every aspect of the
program will unnecessarily delay getting started. Adjustments to
initial decisions can always be made later. A good starting point is
to review the suggestions made by the JCIH
protocols for both the well-baby and neonatal intensive care nurseries. Additional examples of protocols and procedural guidelines
being used by hospitals and state EHDI programs are provided
by the National Center for Hearing Assessment and Management
(NCHAM).
28
4
regarding screening
Which Equipment Is Best?
In the past 20 years, a variety of types of equipment have been
developed that can be used successfully in universal newborn
hearing screening programs. Transient evoked OAE, distortion
product OAE, and AABR equipment have all demonstrated their
practicality and eectiveness in hospital-based newborn hearing screening programs.29 Each type of equipment has its proponents, and debates about which type of equipment is best are
sometimes quite energetic. It is clear, however, that the particular
type and brand of equipment selected are not the most important issue in whether the program will be successful. Equipment
continues to be modified and improved, and it is almost certain
that better, faster, and easier-to-use equipment will become
available. That is no reason, however, to delay implementing a
program. Currently available equipment is more than adequate
for operating a successful newborn hearing screening program.
A brief summary of the issues to be considered in selecting
equipment is available from NCHAM.
28
How Many Tests Should Be Included in the
Screening Protocol?
The purpose of any screening program is to select a subset of the
general population that is at higher risk of having a particular
condition so that a more in-depth diagnostic assessment can be
done with members of that group. Therefore, some false positives (that is, infants with normal hearing who do not pass the
screening test) and occasional false negatives (infants who pass
the screening test but do have a hearing loss) are expected. If only
one screening test is done for each baby before hospital d ischarge,
as many as 10 to 15% of the babies may not pass. Therefore, many
hospitals do two or more screening tests if babies do not pass at
first. Sometimes this is done with the same type of equipment;
sometimes with dierent types of equipment. Furthermore,
some hospitals do a two-stage screening with dierent types
of equipment before the baby is discharged from the hospital;
others do a single-stage screening before the baby is discharged
and then follow with an outpatient screen several days later.
Deciding which protocol is best for a given situation is usually
based on factors such as:
How long babies typically stay in the hospital before discharge
•
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How dicult it is in this area to get parents to come back for
•
rescreens
The availability of dierent types of equipment
•
Who is doing the screening
•
Pearl
More important than the type of equipment used or the protocol
being followed is having someone in charge of the program who
is passionate about the importance of newborn hearing screening and is completely committed to the success of the program.
The fact that successful programs currently use a large variety
of protocols suggests that no one protocol is best for all situations.
Regardless of the protocol used, there should be a written document to guide the activities of the program. Examples of written
otocols are provided by NCHAM.28 Issues to be dealt with in this
pr
protocol are summarized in the following subsections.
5.2.3 Dealing with Procedural Issues
Regardless of the technology and protocol used, several proce-
dural issues are important for an ecient, successful program.
The World Health Organization (WHO)30 recommends that all
newborn hearing screening programs have:
Clearly stated goals with roles and responsibilities for people
•
who are involved
A clearly designated person who is responsible for the program
•
People doing the screening who have received hands-on train-
•
ing in what they are expected to do
Regular monitoring to ensure that the protocol is being cor-
•
rectly implemented
Specific procedures about how to inform parents of results
•
Recording and reporting of information about the screening
•
for each child in the health record
A documented protocol based on local circumstances
•
Who Will Do the Screening?
Reports from hundreds of operational programs provide clear
evidence that newborn hearing screening can be performed by
a wide variety of people, including nurses, audiologists, technicians, health care assistants, volunteers, and students.29 Some
states have laws regarding who can do hearing screening and
how they must be supervised; others do not. Regardless of who
does the screening, those individuals must be properly trained
and supervised, and data should be kept on each screener’s
performance to enable timely and appropriate training and
assistance when needed.
When Should Screening Be Done?
All other things being equal, newborn hearing screening is
faster and easier if babies are quiet and the environment is not
too chaotic. Because of this, it is usually easiest to do screening
during the early morning or the night, when fewer people
(such as doctors, visiting relatives, nurses, or parents) want
access to the baby. However, depending on who is screening,
screeners’ other responsibilities, and how the hospital’s nursery
is organized, screening can be done successfully at other times.
Whatever decision is made, dozens of other hospitals are doing it
at approximately the same time. The conclusion? There really is
no wrong time to do newborn hearing screening.
How Do You Ensure Every Baby Is Screened?
There are many procedures to ensure that no babies are missed.
Setting up a system to log the birth and screening of every baby,
making sure screeners are available to screen every baby before
discharge, and incorporating the hearing screening into the
discharge plan should all be considered. Because some hospitals
discharge babies after very short stays, seven-day-a-week coverage is usually needed. Many screening program coordinators
have found that it is more ecient to incorporate screening
duties into the job responsibilities of existing personnel than
it is to hire dedicated screening sta. However, more and more
hospitals are contracting hearing screening to an external provider. An excellent summary of the pros and cons of outsourcing
newborn hearing screening services is provided by Winston and
31
Roush.
It is often useful to address specifically the issues raised by the
following headings.
Should Screening Be Done with Parents
Present?
Who Is In Charge?
Thousands of hospitals have demonstrated that newborn
hearing screening can easily be incorporated into the routine
of a hospital. As with any other procedure, however, it takes
attention to detail and someone who is ultimately responsible
to make sure that all of the specifics are addressed. The person
responsible for day-to-day operation of the program does not
need specific professional certification, but he or she needs
to have good rapport with the nursery sta, understand how
screening happens, and most of all be committed to the success
of the program. Instead of looking for reasons why newborn
hearing screening will not work, that person needs to be committed to its success.
60
Screening the baby when the parents are present is a wonderful
opportunity for educating parents about the importance of
hearing and language development. However, it requires more
time and, consequently, increases the cost of the screening
program. Even if parents are not typically present for screening,
they should certainly be accommodated if they ask to watch. It
is important to make sure parents are involved and supported at
every opportunity. Parent education should be addressed with
information in the preadmission materials, prenatal classes,
media, or materials placed in the baby’s crib. If, based on this
information, parents do not want to have their baby screened for
hearing loss, they have the right to refuse. It is a good idea to
keep written documentation of such refusals.
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