NEONATAL HEARING SCREENING

The Public Health Association of Australia notes that:

1. Permanent hearing impairment is a significant and relatively common condition in newborns, affecting between 1.3 and 3.1 per 1000 live births.1,2 We would expect approximately 500 births in Australia each year of children with significant hearing impairment10; this is of the order of 10 to 100 times more frequent than the metabolic conditions for which newborn screening occurs at present. Significant permanent hearing impairment, if undetected, will impede and can have profound effects on speech, language, and cognitive development,3 and thus emotional and social well-being.
2. Current international research indicates that babies whose permanent hearing impairment is diagnosed before the age of six months, and who receive appropriate and consistent early intervention, have significantly higher language levels than those children identified after the age of six months.4 ,5 Of children aged 5 years with permanent hearing impairment, it is estimated that 90% have had the impairment since the neonatal period.6
3. Acceptable technologies are now available, viz., measurement of otoacoustic emissions (OAE) and automated measurement of the auditory brainstem response (A-ABR), that enable effective screening of hearing impairment in newborns during natural sleep or quiet rest. Such technology has been used in screening programs since 1990.7,8
· Figures quoted for universal screening programs using OAE and A-ABR show sensitivity (proportion of infants with abnormal hearing who fail the screen) close to 100%, and specificity (proportion of infants with normal hearing who pass the screen) above 90%.8,11
· Currently manufactured A-ABR equipment has a low (2%) false-positive rate.12
4. The average age of diagnosis of hearing impairment in centres which have implemented universal newborn hearing programs ranges from 3 months to 6 months.8,9 The average age of diagnosis of hearing impairment in centres which screen only infants known to have pertinent risk factors is estimated at 24 months.9
5. The cost for two-stage hearing screening per child ranges from $24 to $43 (depending on the technology used) and the cost of a screening program per diagnosis of significant permanent impairment ranges from $12,000 to $22,000, which includes costs of personnel and all equipment, and is well within the range of other screening programs.8,12,13 A successful program will potentially mitigate the cost of the higher teacher-student ratio and greater life-long support required for children whose hearing impairment is diagnosed late.
6. Australia already has excellent facilities for audiological rehabilitation, including the fitting of hearing aids, but limited capacity for diagnosis. All children diagnosed with permanent hearing impairment are fitted with hearing aids, and monitored up to age 21 for a nominal annual fee.
7. These issues satisfy the WHO preconditions14 for the establishment of a screening program.
8. Although a randomised clinical trial to demonstrate the efficacy of neonatal hearing screening has not been conducted, the American National Institutes of Health Consensus Statement, 1993,15 the European Consensus Statement, 1998,16 the American Academy of Pediatrics, 1999,3 and the US Joint Committee on Infant Hearing17 have all supported the introduction of screening. Neonatal hearing screening is mandatory in several states of the USA, and large-scale, but not universal, screening is underway in Western Australia.

The Public Health Association of Australia believes that:

1. Universal neonatal hearing screening is feasible, beneficial, and justified.
2. Principles of equity and efficiency demand the establishment of a program of universal neonatal hearing screening in Australia as soon as possible
3. Prompt diagnosis must be achieved for neonates suspected of being hearing impaired, and prompt intervention must follow for those in whom the impairment is confirmed.
4. To be successful a neonatal hearing screening program should endeavour
· to be universal, since selective screening based on high-risk criteria fails to detect at least half of all infants with congenital hearing loss.9,12
· to be comprehensive in its approach , i.e. it should include training and supervision of personnel, quality assurance, the tracing of identified children, systems for reporting and monitoring outcomes, and counselling for parents.4

5. While existing programs of Universal Neonatal Hearing Screening (UNHS) in other countries have generally sought highest coverage and pass rates by offering UNHS in hospital postnatal wards prior to discharge, with subsequent follow-up in the community;6,16 decreasing length of stay in hospital for obstetric care, and Australian patterns of population distribution and service provision may make community-based screening programs preferable in some areas.
6. Effective universal neonatal hearing screening will not replace the need for vigilance and for continued surveillance of hearing behaviour and language development to detect hearing impairment in children who have not received neonatal screening or who develop permanent hearing loss at a later age.

The Public Health Association of Australia resolves that:

1. Universal neonatal hearing screening should be a coordinated service and requires cooperation of State, Territory and Federal governments.
2. The Federal Government of Australia should facilitate the establishment of a universal neonatal hearing screening program in all States and Territories so that children with permanent hearing impairment can be referred to the national facility for diagnosis, habilitation and treatment (Australian Hearing) at the earliest possible age.
3. Any screening program must be sufficiently resourced to enable high quality monitoring and evaluation.
4. We support a range of national strategies for achieving effective and efficient universal neonatal hearing screening programs for all Australian children.


References:
1. Bamford, J., & Davis, A. (1998). Neonatal hearing screening: a step towards better services for children and families. British Society of Audiology, 32, 1-6.
2. Barsky-Firkser, L., & Sun, S. (1997). Universal newborn hearing screening: a three-year experience. Pediatrics, (99), 6.
3. American Academy of Pediatrics Taskforce on Newborn and Infant Hearing (1999). Newborn and infant hearing loss: Detection and intervention. Pediatrics, 103, (2) 527-530.
4. Yoshinaga-Itano, C., Sedey, A., Coulter, D., Mehl, A. (1998). Language of early-and-later identified children with hearing loss. Pediatrics, 102, (5), 1161-1171.
5. Moeller M. (2000). Early intervention and language development in children who are deaf and hard of hearing. Pediatrics 106(3) e43.
6. Kuhl, P., & Williams, K. (1992). Linguistic experience alters phonetic perception in infants by six months of age. Science, 225, (5044), 606-608.
7. Davis, A., Bamford, J., Wilson, I., Ramkalawan, T., Forshaw, M., & Wright S. (1997). A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment. Health Technology Assessment, 1, (10), 1-176.
8. Arehart, K., Yoshinaga-Itano, C., Thomson, V., Gabbard, S., Stredler-Brown, A. (1998). State of the States: The status of universal newborn hearing identification and intervention systems in 16 states. American Journal of Audiology, 7, (2), 101-114.
9. White, K., Maxon, A. (1995). Universal screening for infant hearing impairment: simple, beneficial, and presently justified. International Journal of Pediatric Otorhinolaryngology, 32, 201-211.
10. Coplan, J. (1987). Deafness: Ever heard of it? Delayed recognition of permanent hearing loss. Pediatrics, 79, 206-214.
11. Birtles, G., Modson, F., Lovegrove, R., Mutton, P., Rosen, J., Starte, D., Williams, K. (1998). Early identification of hearing impairment in children in NSW. Sydney: Parent Council For Deaf Education.
12. Mehl, A., & Thompson, V. (1998). Newborn hearing screening: The great omission. Pediatrics, 101, (1).
13. White, K., Vohr, B., & Behrens, T. (1993). Universal newborn hearing screening using transient evoked otoacoustic emissions: Results of Rhode Island Hearing Assessment Project. Seminars in Hearing, 14, 18-29.
14. Wilson, J.M., Jungner, Y.G. (1968). Principles and practice of mass screening for disease [Spanish] Boletin de la Oficina Sanitaria Panamericana 65(4): 281-393.
15. National Institute of Health (1993). Consensus statement: Early identification of hearing impairment in infants and young children. National Institute of Health Consensus Development Conference Proceedings. Bethesda, MD: National Institute of Health.
16. Grandori F, Lutman M.E. (1998). European consensus statement on neonatal hearing screening finalised at the European Consensus Development Conference, 15 - 16th May, 1998.International Journal of Pediatric Otorhinolaryngol 44(3) 309-310.
17. Joint Committee on Hearing (2000). Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. American Journal of Audiology 9:9-29.


Adopted at the 2000 Annual General Meeting of the Public Health Association of Australia