Universal Screening for Hearing Loss in Newborns - US Preventive ...

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Universal Screening for Hearing Loss in Newborns:Clinical Summary of US Preventive Services Task Force RecommendationPopulationRecommendationAll NewbornsScreen for hearing loss in all newborn infantsGrade: BThe prevalence of hearing loss in newborn infants with specific risk indicators is 10 – 20 times higher than in the general population of newborns.Risk assessmentRisk indicators associated with permanent bilateral congenital hearing loss include:NICU admission for ≥ 2 dfamily history of hereditary childhood sensorineural hearing losscraniofacial abnormalitiescertain congenital syndromes and infectionsApproximately 50% of newborns with permanent bilateral congenital hearing loss do not have any known risk indicators.Screening testsScreening programs should be conducted by using a 1-step or 2-step validated protocol.A frequently-used 2-step screening process involves otoacoustic emissions followed by auditory brain stem response in newborns who fail the first test.Infants with positive screening test results should receive appropriate audiologic evaluation and follow-up after discharge.Procedures for screening and follow-up should be in place for newborns delivered at home, birthing centers, or hospitals without hearing screening facilities.Timing of screeningAll infants should have hearing screening before 1 mo of age.Infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 mo of age.TreatmentEarly intervention services for hearing-impaired infants should meet the individualized needs of the infant and family, including acquisition of communicationcompetence, social skills, emotional well-being, and positive self-esteem.Early intervention comprises evaluation for amplification or sensory devices, surgical and medical evaluation, and communication assessment and therapy.Cochlear implants are usually considered for children with severe-to-profound hearing loss only after inadequate response to hearing aids.Other relevantrecommendationsfrom the USPSTFAdditional USPSTF recommendations regarding screening tests for newborns can be accessed at www.ahrq.gov/clinic/cps3dix.htm#pediatric.For the full recommendation statement and supporting documents (including a summary of the evidence) please go to www.preventiveservices.ahrq.gov.FIGUREClinical summary of USPSTF recommendation.USPSTF AssessmentThe USPSTF concludes that there is moderate certaintythat the net benefit of screening all newborn infants forhearing loss is moderate.CLINICAL CONSIDERATIONSPatient Population Under ConsiderationThe patient population considered here includes allnewborn infants.TABLE 1What the USPSTF Grades Mean and Suggestions for PracticeGrade Grade Definitions Suggestions for PracticeAThe USPSTF recommends the service. There is high certainty that the net Offer/provide this service.benefit is substantial.BThe USPSTF recommends the service. There is high certainty that the net Offer/provide this service.benefit is moderate or there is moderate certainty that the net benefit ismoderate to substantial.CThe USPSTF recommends against routinely providing the service. Theremay be considerations that support providing the service in anindividual patient. There is moderate or high certainty that the netOffer/provide this service only if there are other considerationsin support of the offering/providing the service in anindividual patient.benefit is small.DThe USPSTF recommends against the service. There is moderate or highcertainty that the service has no net benefit or that the harms outweighthe benefits.Discourage the use of this service.I statementThe USPSTF concludes that the current evidence is insufficient to assess thebalance of benefits and harms of the service. Evidence is lacking, of poorquality, or conflicting, and the balance of benefits and harms cannot bedetermined.Read “Clinical Considerations” in the USPSTF RecommendationStatement. If offered, patients should understand theuncertainty about the balance of benefits and harms.144 US PREVENTIVE SERVICES TASK FORCE
TABLE 2Level ofCertaintyHighModerateLowUSPSTF Levels of Certainty Regarding Net BenefitDescriptionThe available evidence usually includes consistent results fromwell-designed, well-conducted studies in representativeprimary care populations. These studies assess theeffects of the preventive service on health outcomes.The conclusion, therefore, is unlikely to be stronglyaffected by the results of future studies.The available evidence is sufficient to determine the effects ofthe preventive service on health outcomes, butconfidence in the estimate is constrained by factorssuch as:the number, size, or quality of individual studies;inconsistency of findings across individual studies;limited generalizability of findings to routine primary carepractice; orlack of coherence in the chain of evidenceAs more information becomes available, the magnitude ordirection of the observed effect could change, and thechange may be large enough to alter the conclusion.The available evidence is insufficient to assess effects onhealth outcomes. Evidence is insufficient because of:the limited number or size of studies;important flaws in study design or methods;inconsistency of findings across individual studies;gaps in the chain of evidence;findings not generalizable to routine primary carepractice; ora lack of information on important health outcomesMore information may allow an estimation of effects on healthoutcomes.The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of apreventive service is correct.” The net benefit is defined as benefit minus harm of the preventiveservice as implemented in a general, primary care population. The USPSTF assigns a certaintylevel on the basis of the nature of the overall evidence available to assess the net benefit of apreventive service.Assessment of RiskRisk factors associated with a higher incidence of permanentbilateral congenital hearing loss include NICUadmission for 2 days, several congenital syndromes,family history of hereditary childhood sensorineuralhearing loss, craniofacial abnormalities, and certain congenitalinfections. However, 50% of infants with permanentbilateral congenital hearing loss do not have anyknown risk factors.Screening TestsScreening programs should be conducted by using a 1-or 2-step validated protocol. A frequently used protocolrequires a 2-step screening process, which includes otoacousticemissions (OAEs) followed by auditory brainstemresponse (ABR) in those who failed the first test.Equipment should be well maintained, staff should bethoroughly trained, and quality-control programsshould be in place to reduce avoidable false-positive testresults. Programs should develop protocols to ensurethat infants with positive screening-test results receiveappropriate audiologic evaluation and follow-up afterdischarge. Newborns delivered at home, birthing centers,or hospitals without hearing screening facilitiesshould have some mechanism for referral for newbornhearing screening, including tracking of follow-up.TreatmentEarly intervention services for hearing-impaired infantsshould be designed to meet the individualized needs ofthe infant and family, including acquisition of communicationcompetence, social skills, emotional well-being,and positive self-esteem. Early intervention includesevaluation for amplification or sensory devices, surgicaland medical evaluation, and communication assessmentand therapy. In recent years, cochlear implants havebecome more available for appropriate candidates; thissurgery is usually considered in those with severe-toprofoundhearing loss only after inadequate response tohearing aids.Screening IntervalsAll infants should have hearing screening before 1month of age. Those infants who do not pass the newbornscreening should undergo audiologic and medicalevaluation before 3 months of age for confirmatory testing.Because of the elevated risk of hearing loss in infantswith risk indicators, an expert panel has made a 2000recommendation that these children should undergo periodicmonitoring for 3 years. 1OTHER CONSIDERATIONSImplementationThirty-nine US states have enacted legislation related touniversal newborn hearing screening (UNHS). Theselaws differ with respect to whether screening is mandatedor encouraged, how results are reported, and howscreening is funded.Research Needs/GapsAdditional studies detailing the correlation betweenchildhood language scores and functional outcomes (eg,school attainment and social functioning) are needed.DISCUSSIONBurden of DiseaseThe focus of UNHS programs is on congenital (as opposedto acquired or progressive) hearing loss that maynot be detected in the newborn period. According to the2000 statement from the Joint Committee on InfantHearing (JCIH), hearing screening should identify infantsat risk for specifically defined hearing loss thatinterferes with development. The targeted hearing lossfor UNHS programs is permanent sensory or conductivehearing loss averaging 30 to 40 dB or more in the frequencyregion important for speech recognition (500–4000 Hz). 1 PCHL occurs in 1 to 3 per 1000 live births.The prevalence for PCHL is higher than for other conditionsscreened for in the newborn period. Children withhearing loss may have difficulty learning grammar, wordorder, idiomatic expressions, and other forms of verbalcommunication. 2 Delayed language and speech, low educationalattainment, increased behavior problems, de-PEDIATRICS Volume 122, Number 1, July 2008 145
Page 1: SPECIAL ARTICLEUniversal Screening
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