Newborn and Infant Hearing Loss: Detection and Intervention (RE9846)
AMERICAN ACADEMY OF PEDIATRICS
Task Force on Newborn and Infant Hearing
This statement endorses the implementation of universal newborn hearing
screening. In addition, the statement reviews the primary objectives,
important components, and recommended screening parameters that characterize
an effective universal newborn hearing screening program.
ABBREVIATIONS. UNHSP, universal newborn hearing screening program; EOAE,
evoked otoacoustic emissions; ABR, auditory brainstem response; CDC,
Centers for Disease Control and Prevention.
Significant hearing loss is one of the most common major abnormalities
present at birth and, if undetected, will impede speech, language, and
cognitive development.1-7 Significant bilateral hearing loss is present
in ~1 to 3 per 1000 newborn infants in the well-baby nursery population,
and in ~2 to 4 per 100 infants in the intensive care unit population.
Currently, the average age of detection of significant hearing loss is
~14 months. The American Academy of Pediatrics supports the statement
of the Joint Committee on Infant Hearing (1994), which endorses the goal
of universal detection of hearing loss in infants before 3 months of
age, with appropriate intervention no later than 6 months of age.8 Universal
detection of infant hearing loss requires universal screening of all
infants. Screening by high-risk registry alone (eg, family history of
deafness) can only identify ~50% of newborns with significant congenital
hearing loss.9,10 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.
To justify universal screening, at least five criteria must be met:
- An easy-to-use test that possesses a high degree of sensitivity and specificity
to minimize referral for additional assessment is available.
- The condition being screened for is otherwise not detectable by clinical
- Interventions are available to correct the conditions detected by screening.
- Early screening, detection, and intervention result in improved outcome.
- The screening program is documented to be in an acceptable cost-effective
Although additional studies are necessary, review of both published
and unpublished data indicates that all five of these criteria currently
are achievable by effective universal newborn hearing screening programs
(UNHSP). 5,13,15-28 Therefore, this statement endorses the implementation
of universal newborn hearing screening. In addition, this statement reviews
the primary objectives, important components, and recommended screening
parameters that characterize an effective UNHSP.
The Academy recognizes that there are five essential elements to an
effective UNHSP: initial screening, tracking and follow-up, identification,
intervention, and evaluation.13,14 The child's physician and parents,
working in partnership, make up the child's medical home and play an
important role in each of these elements of a UNHSP.29
The following are guidelines for the screening element of a UNHSP:
- Universal screening has as its goal that 100% of the target population,
consisting of all newborns, will be tested using physiologic measures
in both ears. A minimum of 95% of newborns must be screened successfully
for it to be considered effective.16,19,21
- The methodology should detect, at a minimum, all infants with significant
bilateral hearing impairment, ie, those with hearing loss >35-decibel
in the better ear.1,16,19
- The methodology used in screening should have a false-positive rate,
ie, 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%.16,17,19-21
- The methodology used in screening ideally should have a false-negative
rate, ie, the proportion of infants with significant hearing loss missed
by the screening program, of zero.21,23
- 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 evoked otoacoustic
emissions (EOAE) and auditory brainstem response (ABR), either alone
or in combination. Both methodologies are noninvasive, quick (<5
minutes), and easy to perform, although each assesses hearing differently.
EOAE measures sound waves generated in the inner ear (cochlea) in response
to clicks or tone bursts emitted and recorded via miniature microphones
placed in the external ear canals of the infant. 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 measures the electroencephalographic waves generated
in response to clicks via three electrodes pasted to the infant's scalp.
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.16,17,19-21 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. Screening
should be conducted before discharge from the hospital whenever possible.
- Each birthing hospital should establish a UNHSP with a designated medical
(physician) director and sufficient staff to perform the following:
- Develop the screening protocol and select the screening method(s).
- Provide appropriate training and monitoring of the performance of staff
responsible for performing hearing screening.
- Provide the parents or guardians information concerning the screening
procedure, costs, potential risks of hearing loss, and the benefits
of early detection and intervention.
- Establish a system that ensures confidentiality and allows the parents
or guardians the opportunity to decline hearing screening. In most
institutions, general hospital consent obtained at time of admission
is considered to be inclusive of routine care, such as newborn hearing
- Ensure that all individuals performing hearing screening are trained
properly in the performance of the tests, the risks including psychological
stress for the parents, infection control practices, and the general
care and handling of infants in hospital settings according to established
hospital policies and procedures.30
- Establish clear guidelines for responsibility of documenting the results
of the screening procedure.
- Develop mechanisms for communicating results of screening in a sensitive
and timely manner to the parents and the child's physician(s). If repeat
screening is necessary after discharge from the hospital, ensure that
appropriate follow-up is provided.
- Work with local, state, and national monitoring systems to identify all
cases of significant hearing loss occurring in infants designated initially
as free of hearing impairment by the UNHSP (false-negatives).
- Secure funding for the program. Funding through third-party reimbursement
is essential to cover the costs of the UNHSP, including the initial
screen(s), as well as of diagnostic and intervention services. The
cost of complete screening in statewide programs ranges from ~$7 to
$26 per infant screened.13 Additional studies (some of which are ongoing)
are necessary to quantify costs of tracking, diagnostic, and intervention
- Collect critical performance data to ensure that each UNHSP meets the
criteria specified in this statement. These data should be reported
in a regular and timely manner to a statewide central monitoring program.
TRACKING AND FOLLOW-UP13-15,26-28
The following are guidelines for the tracking and follow-up elements
of a UNHSP:
Universal screening has as its goal that there will be 100% follow-up
of all infants referred for formal audiologic assessment and for all
infants not screened initially in the birthing hospital whose parents
did not refuse screening. A minimum of 95% successful follow-up is
required for a UNHSP to be considered an effective screening program.
State departments of health, in coordination with programs mandated by
Part C of the Individuals with Disabilities Education Act, should:
- Establish and maintain a central monitoring system for all hearing screening
programs within the state. Critical performance data, including number
of infants born; the proportion of all infants screened; the referral
rate; the follow-up rate; the false-positive rate; and the false-negative
rate should be collected in a timely manner.
- Establish and maintain a tracking program that monitors all referrals
and misses. Monitoring should ensure that children with significant
hearing loss are not missed, ie, all children designated as free of
hearing loss by the UNHSP, but who are later detected to have significant
hearing loss, are identified by the statewide tracking program.
- Develop mechanisms for communicating results of follow-up activities
with the parents/guardians and the child's physician(s), audiologist,
and speech language therapist.29
- Ensure that hearing screening is performed on all out-of-hospital births.
- Report the screening performance parameters of individual hospital-based
UNHSPs within the state in a timely manner.
- Report critical performance data of each UNHSP (without personal identifiers)
to a national Early Hearing Detection and Intervention monitoring program
established by the Centers for Disease Control and Prevention (CDC).
IDENTIFICATION AND INTERVENTION13-15,26-28
The following are guidelines for the identification and intervention
element of a UNHSP:
- 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
- Appropriate and necessary care for the infant with significant hearing
loss should be directed and coordinated by the child's physician within
the medical home, with support from appropriate ancillary services.29
- A regionalized approach to identification and intervention for infants
with significant hearing loss is essential, ensuring access for all
children with significant hearing loss to appropriate expert services.
It is recognized that professionals with demonstrated competency to
provide expert services in the identification and intervention of significant
hearing loss in young infants are not available in every hospital or
community. The child's physician, within the medical home, working
with the state department of health must ensure that every infant with
significant hearing loss is referred to the appropriate professional(s)
within the regionalized system.
- It is anticipated that there will be increased demand for qualified personnel
to provide age-appropriate identification and intervention services
for young infants with significant hearing loss. As a result, there
will be a need for the training and education of additional expert
The following are guidelines for the evaluation element of a UNHSP:
- The UNHSPs should be evaluated on an ongoing and regular basis by the
state monitoring system for performance with regard to parameters enumerated
in "Screening" above.
- Tracking and follow-up should be evaluated on an ongoing and regular
basis by the state monitoring system, as well as through a national
monitoring system to be established by the CDC.
- Intervention services should be evaluated on an ongoing and regular basis
by the state department of health to ensure that sufficient expert
services are available for children identified with significant hearing
loss, that the services are accessible to the children in need, and
that outcomes from interventions provided are effective.
OTHER RECOMMENDATIONS AND ISSUES
The following are additional recommendations of the Academy for developing
- The Academy recommends that each American Academy of Pediatrics chapter
assume a leadership role in state-based efforts to promote optimal
implementation of UNHSPs. Effective statewide programs require broad-based
support and collaboration. Collaboration should include (but not be
limited to) appropriate professional organizations, parent advocacy
groups, deaf and hard-of-hearing adults, physicians, audiologists,
speech and language therapists, nurses, administrators, payers, legislators,
and state departments of health and special education.
- The Academy shall identify, develop, and disseminate educational materials
regarding effective hearing screening programs.13
- To promote additional research and the development of the needed infrastructure
to provide universal newborn hearing screening, the Academy recommends
- The National Institutes of Health support ongoing research to improve
the efficacy of screening, identification, and intervention.
- The Health Resources and Services Administration promote the development
of a state-based early hearing loss identification and intervention
- The CDC establish and maintain a national monitoring and evaluation program
for early hearing loss identification and intervention.
Physicians should provide recommended hearing screening, not only during
early infancy but also through early childhood for those children at
risk for hearing loss (eg, history of trauma, meningitis) and for those
demonstrating clinical signs of possible hearing loss.9,14 Although most
hearing loss in children is congenital (ie, present at birth), a significant
portion of hearing loss is acquired after birth.2-4 Regardless of the
age of onset, all children with hearing loss require prompt identification
and intervention by appropriate professionals with pediatric training
TASK FORCE ON NEWBORN AND INFANT HEARING, 1998-1999
Allen Erenberg, MD
AAP Delegate to Joint Committee on Infant Hearing
James Lemons, MD
Chairperson, AAP Committee on Fetus and Newborn
Calvin Sia, MD
Chairperson, Project Advisory Committee for the Medical Home Program
for Children With Special Needs
David Tunkel, MD
Chairperson, AAP Section on Otolaryngology--Bronchoesophagology
Philip Ziring, MD
Chairperson, AAP Committee on Children With Disabilities
Mike Adams, MD
Associate Director for Program Development, Centers for Disease Control and
June Holstrum, PhD
Behavioral Scientist, Centers for Disease Control and Prevention
Merle McPherson, MD
Director, Division of Services for Children With Special Health Care Needs,
Maternal and Child Health Bureau
Nigel Paneth, MD
Professor of Pediatrics and Epidemiology and Chairperson of the Department
at Michigan State University
Bonnie Strickland, PhD
Chief, Habilitative Services, Division of Services for Children With Special
Health Care Needs,
Maternal and Child Health Bureau
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The recommendations in this statement do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
Copyright © 1999
by the American Academy of Pediatrics.