The proliferation and progress of universal newborn hearing screening (UNHS) programs in the U.S. have been extremely encouraging. This survey, which queried UNHS program administrators of the three largest birthing hospitals in each state, suggests that there remains a need for more coordinated management programs and follow-up services.

By Jess Dancer, EdD & Joanna Haver, MS

Each year, 12,000 newborns—1 in 300—leave U.S. hospitals with some form of hearing impairment.1 These children are often misdiagnosed as mentally retarded, autistic, brain damaged or schizophrenic. Early identification of hearing loss is recognized as a necessary step in the intervention and management of hearing impairment in children.2

Ideally, children with hearing loss should be identified by three months of age and enrolled in an early intervention program by six months of age.3 Unfortunately, hearing impairment often remains undiagnosed until a delay in speech and language is noticed, usually after the age of two.4 By this time, permanent and serious difficulties in acquiring long-term speech and language skills may be present, even if appropriate treatment is provided. Early identification of infant hearing loss would lead to immediate services and intervention strategies, thereby decreasing the detrimental effects of congenital hearing loss on communication, educational and psychosocial development.

Screening of neonates based on high-risk factors has long been used by audiologists to identify hearing loss; however, a high-risk register approach misses as many as 50% of newborns with hearing impairment.5 Universal hearing screening of all newborns as recommended by the National Institutes of Health6 is supported by legislation or pending legislation in 36 states1 and is rapidly becoming the States’ protocol of choice to identify newborns with hearing loss as early as possible.7 The Newborn Infant Hearing Screening and Intervention Act signed into law last year by President Clinton, earmarked $7 million for states to develop infant hearing screening and intervention programs. The American Speech-Language-Hearing Assn. (ASHA) is lobbying for full funding of $15 million in FY2001.8 The Act specifies that three federal agencies will work together to link the programs with community-based intervention efforts, as well as to track the impact of early detection and intervention and help with national data collection, management and research.

Previous investigations9,10 have reported variations in the types of screening programs, personnel and technology used in identifying newborns with hearing loss. The authors wondered whether current infant screening and intervention programs used in large birthing hospitals across the U.S. were more variable or similar to one another in their approaches to identification and management of hearing loss in infants.

Survey Method
A 13-item survey, with some questions taken from Arehart et al.10 for comparison purposes, was sent to 153 birthing hospitals across the U.S. and the District of Columbia. These hospitals represented the three hospitals in each state or district with the highest recorded number of births, according to the American Hospital Association’s Guide to the Health Care Field, 1998-99 edition. The survey consisted of questions related to the type of program, technologies and personnel used, intervention services provided, costs and whether or not the program is state mandated.

The survey was sent to the directors of the Department of Audiology in each hospital along with a self-addressed stamped envelope and a cover letter explaining the purpose of the study. Eighty-two questionnaires were returned for a 54% return rate; however, six arrived unanswered and one arrived too late to be included in data analysis. Results are thus based on 75 returned and completed questionnaires. All states with the exception of Idaho, Nevada, and West Virginia had at least one respondent. The 14 southwestern and central states had the best responses with 67% in each of the two regions.

Results

  • 100% of hospital respondents reported a newborn hearing screening program in place.
  • 72% reported a universal hearing screening program, while 16% reported a combined high-risk register (HRR)/ neonatal intensive care unit (NICU) screening program. Six percent of programs screen only NICU babies and 3% continue to use HHR screenings exclusively. Screening by physician’s order was reported by one site, while one other site was aware of a screening program but did not know the type of program in use (Fig. 1).
  • 48% reported the Auditory Brainstem Response (ABR) as the primary screening tool, while 33% reported a combined ABR/Otoacoustic Emissions (OAE) usage. Only 19% used OAEs alone. All respondents reported using either ABRs, OAEs or some combination of the two tests as their primary test protocol. None listed behavioral audiometry or the Crib-O-Gram as methods for testing neonates (Fig. 2).
  • 49% reported that nurses are the most commonly used personnel to perform screenings, while audiologists ranked second with 44% of respondents and “technicians” third with 36% of respondents. Volunteers and “other professionals” are used by 21% of the hospitals (Fig. 3). รพ 79% reported diagnostic testing as part of their follow-up services, while 75% reported parent counseling. A minority of hospitals provide hearing instrument services (37%), early intervention programs (34%), habilitation (23%), cochlear implants (12%), educational services (9%) and “other” services (32%) (Fig. 4).
  • 27% did not know the cost of their screening program, and 10% did not charge. Those who did respond to the cost question indicated a low of $3 to a high of $175. A wide range of finance sources exists, including charging the patients (16%), billing insurance (23%) and using the hospital budget (21%).
  • 35% were from states that mandate hearing screening for newborns. A large majority (79%) described their programs as “strong” in contrast to only 9% who described their programs as “weak.”

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Fig. 1. Percentage of responses for type of screening
program utilized.
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Fig. 2
. Percentage of responses for type of technology used for infant hearing screening.
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Fig. 3. Percentage of responses for personnel used to perform the screening measures.
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Fig. 4. Percentage of respondents for type of follow-up services provided to infants who fail their screening.

Discussion
The most striking finding of this survey is that all hospitals had some type of newborn screening program, with 72% reporting the use of universal hearing screening. This contrasts with Arehart et al.’s 1998 report10, where only 21% of the birthing sites in 16 states used universal hearing screening. In that study, it was found that 42% still used the HRR and 37% reported the absence of a screening program. While the present study is based on the three largest birthing hospitals in each state or district, Arehart et al.’s data are based on 619 birthing sites in 16 states, without regard to number of births at each site. Since the larger hospitals of the present study are more likely to offer universal hearing screening, differences in the two surveys in respect to the percentage of sites with universal hearing screening programs are to be expected.

It is not surprising that ABRs and OAEs, either alone or in combination, have replaced older methods of newborn hearing screening such as behavioral audiometry or the Crib-O-Gram. These older methods tend to be unreliable, while the newer electrophysiological tests are not only reliable but also highly sensitive to the presence of hearing loss.

The diverse use of “other” personnel to carry out screenings is of major concern, with nurses, technicians, volunteers and other professionals used more often than audiologists to perform the tests. In this respect, the present study agrees with Arehart et al. in that nurses are used most often, while audiologists rank second. Although the use of automated protocols for ABRs and OAEs reduces the decision-making aspects of either “pass” or “refer,” the audiologist-as-counselor is critical to explaining the results of screening to anxious parents and should be available during the screening process, as well as during the diagnostic testing process. Unfortunately, Luterman & Kurtzer-White12 report that audiologists are given little preparation for dealing with the parents of infants with hearing loss, and only 18% have ever taken a counseling course.13

The need for appropriate knowledge and counseling during the hearing screening process was brought home to me (JD) when one of my undergraduate students had her own newborn baby’s hearing screened. She became frustrated and concerned when the technician doing the testing said she knew nothing about the test results and couldn’t tell her anything about her baby’s hearing status. This should never happen to parents, who need immediate information from a skilled and empathetic counselor to begin the process of adjustment to their child’s hearing loss and of informed decision-making.

Another issue of concern for further study is that a minority of hospitals in this survey provides direct follow-up beyond diagnostic testing and counseling. As early as 1994, Bess & Paradise14 expressed concern about the availability of professional follow-up services for the increased number of infants diagnosed with hearing loss through universal screening. They write…“it is improper to screen for a disorder without certainty that facilities for suitable follow-up care of individuals who fail the screen are both available and accessible.”14 More recently, Luterman & Kurtzer-White have echoed this concern, stating that “no screening program should be undertaken without an established comprehensive management program.”12 Since our survey did not provide an option to select “referral” when the hospital did not provide direct follow-up services, this is an issue that warrants further study to find out how involved hospitals are in the management of newborns found to have hearing loss.

Hayes7 reports that states are making rapid progress toward achieving universal hearing screening, although several issues continue to impede the establishment of “effective and comprehensive programs.” She lists these impediments as a lack of mandatory statewide systems for tracking and reporting, a lack of centralized systems for reporting confirmed cases of hearing loss, a lack of data-reporting strategies that facilitate transition of infants and families through a system of care and a lack of understanding about the urgent need for intervention in the earliest months of life. She states that “the development of complete systems of care must become a priority for universal newborn hearing screening to provide its ultimate benefit.”7

A recent report card1 on infant hearing screening issued by the National Committee on Hearing Health graded states on their overall progress in establishing universal hearing screening programs. The “excellent” category was reserved for nine states in which “almost all babies are screened and a statewide system for coordination, training, quality assurance, and follow-up have been established.” These states include Colorado, Connecticut, Hawaii, Iowa, Mississippi, New Mexico, Rhode Island, Utah and Wyoming. The 15 states rated “good” were in the process of developing coordinated systems, while 20 others including the District of Columbia rated a “fair” for statewide efforts but no coordinated system. Seven states received an “unsatisfactory” rating and had no statewide efforts or coordination.

In 1994, Bess & Paradise14 published their controversial paper on the need for waiting until screening sites have coordinated management programs and follow-up services. Despite the often-heated discussion that followed its publication, the paper did much to redouble efforts in those important areas of UNHS systems. In the authors’ opinions, until all states reach the “excellent” category, coordinated management programs and follow-up services need to remain a high priority for the successful establishment of these much-needed programs.

Jess Dancer, EdD, is professor of audiology at the Univ. of Arkansas, Little Rock, and Joanna Haver, MS, is a recent graduate from the Univ. of Arkansas.

References
1. National Campaign for Hearing Health: Report card on infant hearing screening issued by National Campaign for Hearing Health. Hearing Review 2000; 7 (5): 42, 44.
2. U.S. Department of Health and Human Services: Healthy People 2000. National health promotion and disease objectives, 1990. Washington, DC: HHS, Public Health Service.
3. Joint Committee on Infant Hearing: 1994 position statement. Audiol Today 1994; 6: 6-7.
4. Copelan J: Deafness: Ever heard of it? Delayed recognition of permanent hearing loss. Pediatrics 1987; 79, 206-213.
5. American Speech Language Hearing Assn: Audiologic screening of newborn infants who are at risk for hearing impairment. Asha 1989; 31(3), 89-92.
6. National Institutes on Health Consensus Statement: Early identification of hearing impairment in infants and young children. Washington, DC: NIH, 1993: 11, 1-24.
7. Hayes D: State programs for universal newborn hearing screening. Pediatric Clinics of North America 1999; 46 (1): 89-94.
8. American Speech Language Hearing Assn: Press release, March 8, 2000.
9. Blake PE & Hall JW: The status of statewide programs for neonatal hearing screening. Jour Amer Acad Audiol 1990; 1(2), 67-74.
10. Arehart KH, Yoshinaga-Itano C, Thomson V, Gabbard, S.A., & Brown AS.: State of the States: The status of universal newborn hearing screening, assessment, and intervention systems in 16 states, 1998. Amer Jour Audiol 1998; 7: 101-114.
11. American Hospital Assn (AHA): AHA Guide to the Health Care Field, 1998-1999. Chicago: AHA, 1998.
12. Luterman D& Kurtzer-White E: Identifying hearing loss: Parents’ needs. Amer Jour Audiol 1999; 8 (1): 13-18.
13. Crandell C: An update in counseling instruction within audiology training programs, l997. J Acad Rehabil Audiol 1997; 30, 1-10.
14. Bess FH & Paradise JL: Universal screening for infant hearing impairment: Not simple, not risk free, not necessarily beneficial, and not presently justified. Pediatrics 1994; 93(2), 330-334.

Correspondence can be addressed to HR or Jess Dancer, EdD, Univ. of Arkansas-Little Rock, Univ. of Arkansas for Medical Sciences, 2801 S. University, Little Rock, AR 72204; email: [email protected].