Advocating for Universal Newborn Hearing Screening

By Lani Hollenbeck

Universal newborn hearing screening and follow-up is an important detection and intervention program promoting childhood development and the acquisition of fundamental language, social, and cognitive skills. These skills provide the basis for later success in school and in society. In an article titled “A Nurse-Managed Universal Newborn Hearing Screen Program,” Brennan (2004) writes,

The role of the nurse in collaboration with other health care professionals is to promote newborn hearing screening, accompanied by health teaching and counseling to ensure that the infant receives follow-up audiological assessment and the family receives education and support services if the infant does not pass the initial screening. The definition of screening for purposes of this article is: “the detection of individuals with specific unrecognized health risk factors or disease processes that may be occurring.” (Minnesota Department of Health, 2001). Best practices for screening encompass the use of health teaching and counseling in all screening, regardless of whether results are positive or negative. I wish to emphasize the importance of universal newborn hearing screening (UNHS) and identify three actions nurses and other health care professionals can take in promoting health teaching and counseling for families with infants diagnosed with hearing loss.

Review of Literature

Meyer et al (1999) conducted a quantitative study to determine incidence and risk factors for hearing disorders in a selected group of neonates and the feasibility of selective hearing screening. The research enrollment criteria focused on risk factors defined by the Joint Committee on Infant Hearing of the American Academy of Pediatrics (AAP) (2007):

The impact of maternal drug use, birth weight <10^th percentile, persistent pulmonary hypertension, intracranial hemorrhage more than or equal to grade III, and periventricular leukomalacia were also evaluated. Researchers administered auditory brainstem response (ABR) tests to 777 infants. Follow-up examinations of 31 infants revealed persistent hearing loss in 18 infants (13 sensorineural, 5 from mixed disorders, 7 requiring amplification). The authors concluded that hearing screening in high-risk infants detected hearing loss in 5% of the infants who had pathologic ABRs (in 2% of the infants the loss was bilateral). Significant risk factors were familial hearing loss, bacterial infections, and craniofacial abnormalities.

Stone et al (2000) conducted a quantitative study to ascertain if new technology has made UNHS an effective tool. They screened 1002 hospitalized infants at 6 to 72 hours of age. The screening team consisted of a family practice physician, an RN and 2 family practice residents. The cost to find

one infant with sensory neural hearing loss was $22,114. They concluded that distortion product otoacoustic emissions (DPOAE) could be easily accomplished in a normal newborn nursery when a two-stage approach is used. These findings suggest that while DPOAE is an effective screening tool, there are questions of cost-effectiveness and challenges in effective follow-up with families whose newborns initially failed the DPOAE.

In contrast to Stone’s study, Thompson et al. (2000) conducted a literature review including relevant articles from 1994 to September 2000 in MEDLINE, CINAHL, and PyschINFO using keywords such as hearing disorders, infants, newborns, screening, and relevant treatments. The objectives of their research were to identify strengths, weaknesses, and gaps in evidence supporting UNHS and to compare its benefits and harms with those of selective screening of high-risk newborns. Their study indicated that modern screening tests for hearing impairment could improve identification of newborns with profound hearing loss, but the efficacy of UNHS to improve long-term language outcomes remains uncertain.

Brennan (2004) conducted a qualitative study of an institutional universal hearing screening program developed by nurses in collaboration with physicians, audiologists, and otolaryngologists. The study focused on development of the screening program including types of equipment, development of protocols, and personnel, and addressed critical factors in the development of the program utilizing recommendations developed by the AAP. Development of UNHS programs in all birthing hospitals in the U.S. and clarifying the role that nurses play in the development of such programs were identified as goals. Critical factors for successful program development include:

• good fit between the mission and vision of the institution
• a multidisciplinary team
• leadership
• education and coordination
• continuous quality improvement.

Keran et al (2002) utilized a cost-effectiveness analysis model based on the concept that early identification of hearing impairment may improve language outcomes and subsequent school and occupational performance. UNHS can reduce the median age of identification of hearing impairment from 12-18 months to 6 months or less. If early identification can improve language abilities, decrease educational and vocational costs, and increase lifetime productivity, then UNHS has the potential for long-term cost savings compared with selective hearing screening or no screening. Their major finding was that the cost of diagnosing an infant with bilateral moderate to profound deafness by age 6 months was approximately $16,000 using selective screening and $44,000 using UNHS. These costs per infant diagnosed are comparable to screening programs for other newborn conditions such as congenital hypothyroidism and PKU, estimated at $27,000 and $42,000 respectively.

Kezirian et al (2001) utilized a decision analysis model to measure the cost of screening and the number of infants identified with hearing loss through universal screening. Their results indicated that otoacoustic emissions testing (OAE) at birth followed by repeat testing demonstrated the lowest cost ($13 per infant) and had the lowest cost-effectiveness ratio ($5,100 per infant with hearing loss identified). In comparison, screening by Bilateral Auditory Evoked Potential (BAER) at birth with no screening follow-up was the only protocol with greater effectiveness, but it also demonstrated the highest cost ($25 per infant) and a high cost-effectiveness ratio ($9,500 per infant with hearing loss identified). The OAE testing protocol is recommended for screening programs concerned with cost and cost-effectiveness, although there are other caveats to consider.

In summary, these articles all identified the importance of newborn hearing screening utilizing a collaborative approach. Each study attempted to identify best practices including equipment, protocols, and patient selection. Each group studied a different screening methodology’s cost-effectiveness.

Discussion

The National Center for Hearing Assessment and Management (2005) states that every day in the U. S., 33 babies (12,000 each year) are born with permanent hearing loss. It is the most frequently occurring birth defect (3 of every 1000 newborns). Average age at identification has been 2.5-3 years of age, with many children not identified until 5-6 years of age (Commission on Education of the Deaf, 1998). If hearing loss remains undetected, even mild loss or loss in one ear has substantial detrimental consequences. For example, children with hearing loss in one ear are ten times as likely to be held back at least one grade compared to a matched group of children with normal hearing. Accordingly, by the time the child reaches high school, more than $400,000 per child in special education costs can be saved if the child is identified early and given appropriate educational, medical, and audiological services.

In 1992, the National Institutes of Health (NIH) issued a consensus statement establishing guidelines for UNHS programs in the United States. In 1994, the Joint Committee on Infant Hearing of the AAP also published a policy statement endorsing UNHS, and reiterated that recommendation in an updated policy statement published in October 2007. The importance of UNHS was further underscored by its inclusion as a goal in Healthy People 2010, “to increase the proportion of newborns who are screened for hearing loss by age 1 month, have audiological evaluation by age 3 months, and are enrolled in appropriate intervention services by age 6 months” (U.S. Department of Health and Human Services, 2000, p. 28). NIH action was necessary because hearing loss was not being detected in children until an average age of 30 months. Children with milder hearing loss were often not identified until school age (Brennan, 2004). Currently 46 states, 2 territories, and the District of Columbia have early hearing detection and intervention laws or voluntary compliance programs that screen hearing. As a result, 95% of infants are now screened, usually before leaving the hospital.

Although great strides have been made, significant work remains in order to ensure that newborns with hearing loss receive timely and appropriate services. About half of those referred for diagnosis are lost to follow-up. An estimated one-third of the babies who stay in the system do not receive diagnostic evaluations by 3 months of age. In addition, more than half of the infants diagnosed with hearing loss are not enrolled in early intervention programs by 6 months of age (American Speech-Language-Hearing Association Hearing Facts 2007). In Minnesota, birthing hospitals have implemented UNHS one by one over the past 10 to 12 years, with program support from the Minnesota Department of Health. Effective September 1, 2007, newborn hearing screening is now mandated in Minnesota, and protocols for screening and follow-up have been developed by a task force of pediatric audiologists.

As a social policy issue, cost and cost-effectiveness are critical aspects of mandated UNHS. State directors of speech and hearing programs characterized the most serious barriers as financial: cost and reimbursement for screening (Kezirian et al., 2001). According to the National Institute on Deafness and Other Communication Disorders (2005),

Lasting parental anxiety and an adverse effect on the parent-child relationship have been cited as risk factors related to universal screening and false-positive results. With UNHS becoming routine practice, understanding the impact of parental anxiety and potential vulnerabilities is important for parent education. Maternal anxiety related to a false positive result was examined in a total of 5010 infants using the ABR screening method. Nine percent of mothers said they “treated their child differently” before outpatient rescreening, and 14% reported lasting anxiety even after their children had passed the outpatient rescreenings. Although some of the mothers reported anxiety, more than 90% believed that UNHS was a good idea (Clemens et al, 2008

Nurses have an important role to play in advocating for newborn hearing screening. Through the therapeutic use of self and in our work with families of newborns and infants, nurses have the opportunity to educate and influence those we care for. The role of the nurse is crucial in advocating for follow-up hearing assessment if an infant fails the initial hearing screen.

Ideally, the nurse caring for the family is familiar with newborn and infant developmental milestones, including speech and language. In addition, the nurse should understand the relationship between hearing and speech development, risk factors for hearing loss, and hearing screening and follow-up resources available within the context of the care setting. The nurse is in a unique position to support the family through the screening process using attributes of listening, encouraging, and addressing their concerns or lack of knowledge about hearing testing and subsequent follow-up if needed.

Three specific nursing actions can support families with newborns and infants in need of initial or follow-up hearing testing:

In our interactions and communication with families, nurses have the potential to either promote or dismiss the importance of follow-up hearing examinations. Many families tell me that the reason they brought their child back to the hospital for follow-up was not because they wanted to, but because “the nurse said it was important for me to do this for my baby.” While the nurse’s belief in health promotion and screening may be based on prior positive or negative experiences, it is my hope that nurses will listen to parents’ concerns, fears, and anger about their child’s possible hearing loss, and validate their feelings. According to Klass (2003), “it is important for the nurse to acknowledge parental feelings, provide support, assist parents to identify their contributions to positive development of the child, and provide needed education” (p. 738). It is imperative that nurses utilize their skills to encourage follow-up examination and provide support for families. This will only occur if nurses are fully aware of their own feelings about caring for children with hearing deficits and their beliefs about whether early intervention can make a difference in a child’s life-long learning capability.

Follow-up hearing evaluations can be promoted by ensuring that parents fully understand their child’s screening results and the importance of diagnostic audiological evaluation, and are provided with the necessary contact and resource information. In Minnesota, the Department of Health provides informative brochures about hearing screening and follow-up, available in English, Spanish, Somali, Hmong and Mandarin.

As nurses collaborating with other health care professionals, we need to promote strategies to develop professional and institutional protocols in which we communicate accurate information collegially and sensitively. A family-centered approach is ideal, because families are the first line of care for their infants and are empowered to make sure that their child receives the best health care treatment possible. Each child and family should have an identified medical clinic, to facilitate centralizing information about the child’s health history. Combining follow-up hearing exams with well baby checks is an excellent way to maximize use of a family’s precious time. Involving the entire family in the screening or follow-up can be empowering. Sensitivity to cultural beliefs related to medical procedures, and other differences such as ethnicity, race, socioeconomic background, and religion, is important. Families’ contact information should be verified during each interaction to facilitate follow-up. Ideally there is strong institutional support for hearing screening within the facility where care is provided. We need to equip parents to make decisions and help them identify their strengths and resources.

Conclusion

In conclusion, the use, ramifications, and results of UNHS as a tool in caring for newborns is an important topic that should concern all nurses. The nursing role is invaluable in promoting UNHS as part of newborn intervention and in promoting and performing health teaching and counseling for families with infants diagnosed with hearing loss.

References

American Speech-Language-Hearing Association. Hearing facts on newborn hearing loss and screening. 2007. Available at www.asha.org. Accessed December 2007.

Brennan, R. (2004). A nurse-managed newborn universal hearing screen program. The American Journal of Maternal/Child Nursing, 29(5), 320-325. Retrieved January 31, 2005 from CINAHL database.

Clemens CJ, Davis SA, Bailey AR. The false-positive in universal newborn hearing screening. Pediatrics 2000: 106. Available at http://pediatrics.aappublications.org/cgi/content/full/106/1/e7 Accessed December 2, 2007.

Joint Commission on Infant Hearing (JCIH) 2007 position statement on early diagnosis and intervention for infants with hearing loss. Pediatrics 2007: 120:898-921. Retrieved October 10, 2007 from CINAHL database.

Keran R, Helfand M, Homer C, McPhillips H, &Lieu TA (2002). Projected cost effectiveness of statewide universal newborn hearing screening. Pediatrics 110(5), 855-865. Retrieved February 5, 2005 from CINAHL database.

Kezirian, E., White, K., Yueh, B., & Sullivan, S. (2001). Cost and cost-effectiveness of universal screening for hearing loss in newborns. Otolarynology-head and neck surgery, 124(4), 359-367.

Klaas, D. (2003). Caring for vulnerable populations. In J. E. Hitchcock, P. E. Schubert, & S. A. Thomas. (Eds.), Community health nursing caring in action (p. 738). Clifton Park, N.Y: Thomson Delmar Learning.

McCartney, P. R. (1999). Newborn hearing screening: what nurses think. The American Journal of Maternal/Child Nursing, 24(1), 48-49. Retrieved January 31, 2005 from CINAHL database.

Meyer, C., Witte, J., Hildmann, A., Hennecke, K.H., Schunck, K.U., & Maul, K. (1999). Neonatal screening for hearing disorders in infants at risk: Incidence, risk factors, and follow-up. Pediatrics, 104(1), 900-904. Retrieved February 1, 2005 from CINAHL database.

Minnesota Department of Health. (2001). Public health interventions: Applications for public health nursing practice. St. Paul, MN.

National Center For Hearing Assessment and Management (2004) Universal hearing screening fact sheet, Retrieved January 31, 2005, from www.infanthearing.org

National Institute On Deafness and Other Communication Disorders (2005) When a newborn does not pass the hearing screening, Retrieved February 7, 2005, from www.nidcd.nih.gov/health/hearing

Stone, K.A., Smith, B.D., Lembke, J. M., Clark, L.A., Leroy, A., & McLellan, M.B. (2000). Universal newborn hearing screening. The Journal of Family Nursing Practice, 49(11), 1012-1016. Retrieved February 1, 2005 from CINAHL database.

Thompson, D.C., McPhillips, H., Davis, R.L., Lieu, T.A., Homer, C.J., & Charles, J. (2001). Universal newborn hearing screening: Summary of evidence. Journal of the American Medical Association, 286(16), 2000-2010. Retrieved February 1, 2005 from CINAHL database.

U.S. Department of Health and Human Services (2001). Healthy people 2010 fact sheet. Retrieved January 21, 2005, from http:/www.healthypeople.gov/About/hpfact.htm

Weiss, Kate M, MS, CCC-A, pediatric audiologist. November 29, 2007 (personal interview).